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Reporting Fraud, Waste and Abuse
 

Community First Health Plans recognizes that the detection, investigation and prevention of waste, abuse and fraud are vital to maintaining an affordable health care system in this state and country. Community First has mounted a sincere effort to limit waste, fraud and abuse through the efforts summarized in the Community First Anti-Fraud Work Plan.

Community First is committed to protect and preserve the integrity and availability of health care resources to our recipients, our healthcare partners and the general community. Community First performs these activities through its Special Investigation Unit to detect, prevent and eliminate waste; abuse and fraud at the provider, recipient and health plan level. Community First utilizes electronic systems and training of our employees, contractors and agents to identify and report possible acts of waste, abuse and fraud. When such acts are identified, Community First seeks effective remedies to identify overpaid amounts; prevent future occurrences of waste, abuse and fraud; and report offenses to the appropriate agencies.

Fraud is an intentional representation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself/herself or some other person.

If you suspect a person who receives benefits or a provider (a doctor, dentist, counselor, etc.) has committed waste, abuse or fraud, you have a responsibility and a right to report it.

Reporting Waste, Abuse or Fraud by a Provider or Client

  • You can report directly to your health plan any providers or clients you suspect of waste, abuse or fraud by completing the following forms and mailing to address below or faxing to the number below. You may also leave an anonymous message by calling the Community First Hotline.

    PDF fileProvider

    PDF fileClient


    Toll-free: 1-800-434-2347
    Hotline: (210) 358-6332
    Fax: (210) 358-6014

    Community First Health Plans
    Attn: Special Investigation Unit
    12238 Silicon Drive, Suite 100
    San Antonio, TX 78249


  • Or if you can get on the Internet, go to www.hhsc.state.tx.us and select the "Reporting Waste, Abuse and Fraud" tab on the left side of the screen. The site tells you about the types of waste, abuse and fraud to report. If you cannot get on the Internet and you would rather talk to a person, call the HHSC Office of Inspector General Fraud Hotline at 1-800-436-6184. You also can send a note or letter to the following addresses:

 

To report providers, use this address:

Office of Inspector General
Medicaid Provider Integrity/Mail Code 1361
P.O. Box 85200
Austin, TX 78708-5200


To report clients, use this address:

Office of Inspector General
General Investigations/Mail Code1362
P.O. Box 85200
Austin, TX 78708-5200


To report waste, abuse or fraud, gather as much information as possible.
  • When reporting about a provider (doctor, dentist, counselor, etc.) include:
    • 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

  • When reporting about someone who receives benefits, include:
    • 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

 

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Community First Health Plans is an affiliate of the University Health System.