Betrug und Missbrauch

The Department of Human Services (DHS) has mandated minimum requirements for Medical Assistance to ensure that Carelon and Carelon providers are preventing and detecting potential fraud, waste and abuse. 

  • Betrug: Jede Art von vorsätzlicher Täuschung oder Falschdarstellung mit dem Wissen, dass die Täuschung der Person, die sie begeht – oder einer anderen Person – einen unbefugten Vorteil verschaffen könnte. Der Versuch selbst ist Betrug, unabhängig davon, ob er erfolgreich ist oder nicht
  • Verschwendung: Umfasst die übermäßige Nutzung von Diensten oder andere Praktiken, die direkt oder indirekt zu unnötigen Kosten führen. Verschwendung wird im Allgemeinen nicht als durch vorsätzliches Handeln verursacht angesehen, sondern entsteht, wenn Ressourcen missbraucht werden.
  • Missbrauch: Wenn Gesundheitsdienstleister oder Lieferanten die guten medizinischen Praktiken nicht befolgen, was zu unnötigen oder übermäßigen Kosten, falscher Zahlung, Missbrauch von Codes oder medizinisch nicht notwendigen Dienstleistungen führt.

In the Pennsylvania HealthChoices Behavioral Health Program Standards and Requirements, Appendix F obliges Carelon and Carelon providers to comply with Federal and State regulations and implement compliance programs and efforts that prevent and detect fraud, waste, and abuse. Subsequently, Carelon has implemented a compliance and program integrity plan with policies and procedures, trainings, and reporting responsibilities. The complete documentation for Carelon requirements are outlined on the Carelon Fraud and Abuse webpage available at the following address:


The Special Investigations Unit (“SIU”) investigates suspected incidents of FWA for all types of services. Carelon may take corrective action with a Provider or Facility, which may include, but is not limited to:

  • Written warning and/or education: Carelon sends letters to the Provider or Facility advising the Provider or Facility of the issues and the need for improvement. Letters may include education or requests for repayment, or may advise of further action.
  • Medical record review: Carelon reviews medical records to investigate allegations or validate the appropriateness of Claims submissions.
  • Edits: A certified professional coder or investigator evaluates Claims and places payment or system edits in Carelon’s Claims processing system. This type of review prevents automatic Claims payments in specific situations.
  • Recoveries: Carelon recovers overpayments directly from the Provider or Facility. Failure of the Provider or Facility to return the overpayment may result in reduced payment for future Claims, termination from our network, or legal action.

Richtlinien und Verfahren

Carelon has established policies and procedures to meet the DHS requirements specific to the prevention and detection of fraud, waste, and abuse (FWA). All Carelon providers are responsible to meet the requirements on the Carelon Fraud and Abuse webpage. Carelon will announce updates to or revisions to the Carelon Fraud and Abuse webpage in the Compliance Alert Section of Wert hinzugefügt, Carelon’s monthly provider newsletter.

Obligatorische Schulungen

All providers are required to have at least one representative attend an Annual Fraud and Abuse Training offered by Carelon. The provider or provider representative is responsible for reporting all information at the training to the provider and/or the entire staff of the provider agency. If a provider is unable to attend the Fraud and Abuse Training, the provider is responsible to independently review the mandatory training and document when the training is completed within their records. Check the Webseite für Anbietertrainings für Betrugs- und Missbrauchsschulungstermine.

All new providers are responsible to complete and review the documentation and previous trainings available on the Carelon Webseite für Betrug und Missbrauch. Alle neuen Anbieter müssen an einem der vierteljährlich angebotenen Webinare zu Betrug und Missbrauch bei neuen Anbietern teilnehmen. Überprüf den Webseite für Anbietertrainings für verfügbare Daten.


Alle Anbieter sind verpflichtet, mutmaßlichen Betrug und Missbrauch zu melden. Wenn jemand den Verdacht hegt, dass ein Mitglied oder Anbieter (eine Person, die Leistungen erhält) Betrug, Verschwendung oder Missbrauch begangen hat, hat er das Recht, dies zu melden. Keine Person, die Verstöße oder mutmaßlichen Betrug und Missbrauch meldet, wird dafür mit Vergeltungsmaßnahmen geahndet. Der Name der Person, die den Vorfall meldet, und ihre Rückrufnummer werden von den Ermittlern streng vertraulich behandelt.

Bedenken melden per:

  • Besuch At the top of the page click “Report it” and complete the “Report Waste, Fraud and Abuse” form. For the “Who is the insurance company?” dropdown, select “Carelon”
  • Anbieterdienste anrufen

Any incident of fraud, waste or abuse may be reported to Carelon anonymously; however, Carelon’s ability to investigate an anonymously reported matter may be limited if Carelon doesn’t have enough information. Carelon encourages Providers and Facilities to give as much information as possible. Carelon appreciates referrals for suspected fraud, but be advised that Carelon does not routinely update individuals who make referrals as it may potentially compromise an investigation. Learn more at

The Department of Human Services has established a hotline to report suspected fraud, waste, and abuse committed by any entity providing services to Medical Assistance recipients. The hotline number is 1-866-DHS-TIPS (1-844-347-8477) and is available between the hours of 8:30 AM and 3:30 PM, Monday through Friday. Voice mail is available at all other times. Callers do not have to give their name and may call after hours and leave a voice mail if they prefer.

Some common examples of fraud, waste and abuse are:

  • Abrechnung oder Belastung von Empfängern von medizinischer Hilfe für versicherte Leistungen
  • Mehrfache Abrechnung für denselben Service
  • Abgabe von Generika und Abrechnung von Markenmedikamenten
  • Falsifying records
  • Unangemessene oder unnötige Dienste ausführen

Suspected fraud, waste and abuse may also be reported via the website at:—General-Information.aspx

You do not have to give your name if you use the website or email to report fraud, waste or abuse. The website contains additional information on reporting fraud, waste and abuse