Report Fraud, Waste and Abuse
Iowa Total Care takes the detection, investigation, and prosecution of fraud and abuse very seriously, and has a fraud, waste, and abuse program that complies with all federal and State of Iowa laws.
Iowa Total Care in conjunction with its parent company, Centene, operates a fraud, waste, and abuse unit, which routinely conducts audits to ensure compliance with billing regulations.
Our sophisticated code editing software performs systematic audits during the claims payment process. To better understand this process, please review the Billing Manual. In addition, the Iowa Total Care Special Investigations Unit (SIU) performs retrospective audits of medical records to ensure that they support the claims submitted by a provider.
These actions include but are not limited to:
- Remedial education and training to prevent the billing irregularity
- More stringent utilization review
- Recoupment of previously paid monies
- Termination of provider agreement or other contractual arrangement
- Referral to a state or federal law enforcement agency
- Any other remedies available to rectify
Some of the most common fraud, waste, and abuse practices include:
- Unbundling of codes
- Up-coding services
- Add-on codes billed without primary CPT
- Diagnosis and/or procedure code not consistent with the member’s age/gender
- Use of exclusion codes
- Excessive use of units
- Misuse of Benefits
- Claims for services not rendered
How to report suspected Fraud, Waste, and Abuse
Suspected fraud, waste or abuse can be reported to the Iowa Total Care hotline at 1-866-685-8664 or by contacting the health plan’s Compliance Officer at 1-833-404-1061 or email us. All reports are confidential and callers can remain anonymous.
To report potential fraud, waste or abuse directly to the Iowa Department of Human Services, please call.
- Phone: 1-877-446-3787
To report waste, abuse, or fraud, gather as much information as possible.
If your report concerns a healthcare provider,(e.g. doctor, dentist, counselor, etc.) please provide us with as much information as possible. For example:
- Name, address, and phone number of provider
- Name and address of the facility (hospital, nursing home, home health agency, etc.)
- Medicaid number of the provider and facility, if you have it
- Type of provider (doctor, dentist, therapist, pharmacist, etc.)
- Names and phone numbers of other witnesses who can help in the investigation
- Dates of events
- Summary of what happened
If your report concerns someone who is receiving Medicaid benefits, please provide us with as much information as possible. For example:
- The person’s name
- The person’s date of birth, Social Security Number, or case number if you have it
- The city where the person lives
- Specific details about the waste, abuse, or fraud