Fraud, as defined by Center for Medicare and Medicaid Services, CMS, is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in the payment of unauthorized benefits. A scheme does not have to be successful to be considered fraudulent.

Abuse involves actions that are inconsistent with sound medical, business, or fiscal practices. Abuse, directly or indirectly, results in higher costs to the healthcare program through improper payments that are not medically necessary.

The primary difference between fraud and abuse is a person's intent. That is, did they know they were committing a crime?

AultCare's Fraud and Abuse Protection Mission
The mission of AultCare's Special Investigation Unit, SIU Department, is to protect our customers, including companies, enrollees and employees against fraud and abuse by investigating all unlawful activity directed at the corporations assets and to seek remedies for the benefit of the company's policyholders.

How AultCare Works to Protect You
AultCare maintains a committed Anti-Fraud Unit. Our unit works closely with National Health Care Anti-Fraud Association (NHCAA), the Department of Health and Human Services Office of Inspector General (HHS-OIG), the Federal Bureau of Investigation (FBI), the United States Attorney's Offices, and other partners to identify fraud and abuse. We develop cases for referral to local and federal law enforcement authorities, support civil and/or criminal prosecutions, recover lost money, and pursue the exclusion of bad providers from the AultCare system.

What to Look For
Fraud and abuse can take many forms. Some common forms may include, but are not limited to:
• Billing for services or supplies never provided.
• Misrepresenting the services rendered.
• Misrepresenting the diagnosis to justify payment for services.
• Altering claim forms to obtain higher payment amount.
• Soliciting, offering or receiving a kickback, bribe or rebate
• Deliberately applying for more than one payment for the same service.
• Unlawfully completing a Certificate of Medical Necessity.
• Falsifying documents.
• Misrepresenting the place of service.
• Secret, unlawful agreements between a supplier, beneficiary, and/or other
healthcare provider that results in higher costs or charges to AultCare.

What Happens After Suspected Fraud is Reported?
The AultCare SIU Department will begin researching materials such as claims records. At that point, an investigator may request relevant medical documentation from the parties involved. All materials are then analyzed before a final determination is made.

In order for us to provide you with this service, you will need to supply the requested information. See our privacy statement for more information about our policies.

All information received is strictly confidential. Please notify AultCare if you suspect healthcare fraud and abuse against the company using the following resources:

ONLINE - E-mail is secure and encrypted for your protection.

MAIL OR FAX - You can print the following form or just write the company and send to the following:
Click here for printable Special Investigation Unit Form.
FAX - (330) 363-3125

MAIL - AultCare
SIU Department
P. O. Box 6910
Canton, Ohio 44706-0910
HOTLINES - (330) 363-2887 (local) or (800) 204-5119 (out of area)

All calls are confidential and can be made 24 hours per day, seven days per week. It is also your prerogative to remain anonymous.