Fraud, Waste & Abuse

Our Special Investigations Unit investigates allegations of fraud, waste and abuse. Below you will find more detail about these terms:

  • Fraud – intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or another person. This includes any act that constitutes fraud under applicable Federal or State law.
  • Waste – the misuse, underutilization or overutilization of items or services.  This could also be any other inappropriate or unnecessary billing, or medical practices that directly or indirectly add to health care costs.  This also includes unwarranted or unexplained variations in care that result in no discernible differences in health or patient outcomes.
  • Abuse – provider practices that are inconsistent with sound fiscal, business or medical practices, and result in unnecessary cost to the Medicaid program. Abuse could also result from reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. This includes beneficiary practices that result in unnecessary cost to the Medicaid program.

Any of the above actions could result in a Notice of Overpayment from the Special Investigations Unit.

To report fraud, waste or abuse, call the Vaya Health Confidential Compliance (Fraud and Abuse) Hotline:  1-866-916-4255 (24 hours a day, seven days a week.) You can also report online.

Vaya Health encourages all members of our community, including consumers, family members and provider employees, to report potential Medicaid fraud, waste or suspicious billing practices. You may always report anonymously. If you do reveal your name, we may need to contact you for more information.

Call 1-800-849-6127 toll free 24/7 to obtain services and support for mental health, developmental disabilities and substance abuse. Members can request materials in Spanish or English.

Llamar al número gratuito 1-800-849-6127 24/7 para obtener servicios y apoyo a la salud mental, discapacidades de desarrollo y abuso de sustancias. Los miembros pueden solicitar materiales en español o Inglés.