Fraud and Abuse

WPS is committed to detecting, correcting and preventing health care and prescription drug fraud and abuse. The following information will help you to identify and report any suspected cases of fraud or abuse in regard to your WPS Medicare Part D prescription drug plan.  Fraud makes the program more costly for everyone.

What is Fraud? Health care and prescription drug fraud is defined as making false statements or representations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist.  These acts may be committed either for the person’s own benefit or for the benefit of some other party.  In order to prove that fraud has been committed against the Government, it is necessary to prove that fraudulent acts were performed knowingly, willfully, and intentionally.

What is Abuse? Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Part D prescription drug program.  Many times abuse appears quite similar to fraud except that it is not possible to establish that abusive acts were committed knowingly, willfully, and intentionally. 

Who can commit Fraud or Abuse? Anyone, including pharmacies, physicians/prescription drug prescribers, drug manufacturers, Medicare Part D plan sponsors, insurance agents, and even Medicare Part D beneficiaries.

Some examples of Fraud and Abuse
Pharmacies

• Billing for drugs not dispensed
• Billing for covered brand-name drugs when generic drugs were dispensed

Physicians/Prescribers

• Over-prescribing drugs
• Accepting kickbacks from manufacturers to prescribe certain drugs

Drug Manufacturers

• Payment of kickbacks to prescribers to induce prescribing of certain drugs

Medicare Part D Plan Sponsors and Insurance Agents

• Improper marketing activities, including offering Medicare beneficiaries a cash payment to induce them to enroll, or misrepresenting the benefits of a plan being marketed

Medicare Part D Beneficiaries

• Doctor shopping, which occurs when a beneficiary consults more than one doctor to inappropriately obtain multiple prescriptions for narcotics or other drugs
• Identity theft, which occurs when one person uses another person’s Medicare beneficiary information to illegally obtain prescriptions

To report suspected Fraud or Abuse: Use our online form or call our toll-free Fraud and Abuse Hotline at 1-888-766-4681.  We encourage you to report any suspicious activity.  You may make your report anonymously if you wish.