Compliance Spotlight: Fraud, Waste and Abuse

92816compliancefraud640A cornerstone of Texas Children’s Compliance Program is the prevention and detection of fraud, waste and abuse. All Texas Children’s workforce members are required to report any suspected fraud, waste and abuse.

What is fraud?

Fraud is an intentional act that results in some unauthorized health care benefit. Typically involves deceit or misrepresentation. Examples include:

  • Intentionally billing for services or medical tests that were never performed
  • Falsifying records or statements to get a claim paid or approved
What is waste?

Waste is the overutilization of services or other practices that result in unnecessary costs to the health care system. Often not intentional, but results in misuse of resources. Examples include:

  • Mistakenly billing twice for the same goods or services
  • Coding errors that result in higher bills to payers
What is abuse?

Abuse is defined as provider practices (i) that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary health care costs, or (ii) that result in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards. Examples include:

  • Inflating the actual work performed, or billing for the highest level of service when in actuality a lower level of service was delivered
  • Billing for unlicensed or unapproved drugs or services
  • Failing to obtain proper physician certifications before patients are treated with certain therapies
Preventing fraud, waste and abuse
  • Texas Children’s documentation and coding policies support accurate billing for services provided to our patients, and require workforce members to understand and abide by the laws, regulations, policies and procedures that apply to them in the performance of their job duties.
  • In addition, the Compliance and Privacy Office conducts scheduled and unscheduled audits or reviews of our programs and services with particular emphasis on risk areas identified by the federal government and experts in the field.
  • Mistakes or errors on bills that result in overpayments are returned promptly in accordance with applicable laws.
What do I do if I suspect fraud, waste or abuse?

Workforce members have a duty to report suspected fraud, waste or abuse. Any concern should be shared with your immediate supervisor, manager or the Compliance and Privacy Office (832-824-2085 or compliance@texaschildrens.org). Alternatively, an anonymous report can be made by calling the Texas Children’s Confidential Hotline at 1-866-478-9070. This Hotline is available 24 hours a day, 7 days a week.

Our policies prohibit retaliation against any person who reports, in good faith, an actual or perceived violation of our Compliance Program or other applicable laws, regulations or policies.

Applicable Policies and Procedures
  • Compliance with the Deficit Reduction Act (DRA) Policy
  • Compliance with the Deficit Reduction Act (DRA) Procedure