Fraud and abuse in health care is a serious problem that affects everyone. It leads to higher health care costs for patients, providers, taxpayers, and businesses. There are federal and state laws that make it a crime to commit fraud or abuse.
We need to know if a treatment agency paid by us may be committing fraud or abuse. We need to know if a person who has Oregon Health Plan (OHP) insurance may be committing fraud or abuse. If you suspect or know about fraud or abuse, we want you to report it. You do not need to give your name when you make a report about fraud or abuse.
What is Fraud? This is when a person gives false information on purpose, and they benefit from it. The person may be a provider, or a client or consumer. Some examples of fraud are:
• A provider bills us for services that were not provided
• A person gives false information about their income in order to qualify for OHP insurance
• A provider puts false information in a medical record to get paid for non-covered services
• A person uses someone else’s DHS Medical Care ID to get OHP services
What is Abuse? This is when a person’s actions or decisions result in unneeded or extra costs to BCN or OHP. The person may be a provider, or a client or consumer. Some examples of abuse are:
• A provider gives more treatment or services than what is needed for the person’s medical problem and needs
• A provider’s treatment or services do not meet professional standards
• A person goes to the emergency department for non-emergency services
Who Can Make a Report? Anyone who suspects or knows about fraud or abuse can make a report. This includes:
• BCN employees and contractors
Employees and contractors of BCN member counties and provider agencies
• Individual providers
• OHP members
Employees and contractors of BCN business partners and affiliates
• Members of the public
Your report can be anonymous if you wish.
There are federal and state “whistleblower” laws that protect the right of employees to report suspected fraud or abuse. These laws protect against retaliation by the employer when an employee has in good faith reported about possible criminal activity or cooperates with any related investigation or legal proceeding.
How to Report Fraud or Abuse. We want to know about possible fraud or abuse involving a treatment agency paid by us. We want to know about possible fraud or abuse involving a person who has OHP insurance.
If you suspect or know about fraud or abuse, there are two ways to make a report. Choose the way that works best for you.
• Telephone. Call us toll-free at: 1-866-370-5525
• Postal mail. Print and fill out the Reporting Form (PDF) at the bottom of this page. There are instructions on page 2 for where to send the form.
When you make a report, please give as much specific information as possible.
We cannot give information about the status of a fraud or abuse report. We cannot give information about the findings from a report. Information about suspected or known fraud, waste or abuse may be shared with the Oregon Department of Human Services or the Oregon Health Authority and other government agencies. This is required by federal and state laws.