Reporting Fraud, Waste and Abuse
Abuse means causing any physical, sexual or mental injury to you. This can also be taking advantage of your financial resources.
- Physical abuse. Any inappropriate contact that causes bodily harm. For example, being slapped, scratched, or pushed. Being threatened with a weapon, such as a knife or a gun, is another example.
- Sexual abuse. Any sexual behavior or intimate physical contact that occurs without your permission. This can be touching your genital area, buttocks or breasts.
- Mental abuse. When you feel emotional distress resulting from the use of demeaning or threatening words. This can also include signs, gestures and other actions. For example, controlling behavior, embarrassment or social isolation are types of mental abuse.
- Financial Abuse. When someone uses your money without your consent. This includes improper use of guardianship or power of attorney.
“Fraud” means to knowingly get benefits or payments that you are not entitled to receive. Please let us know if you are aware of someone who is committing fraud. This could be a provider or a member. Some examples of healthcare fraud include:
- Loaning, selling, or giving your CeltiCare Health Member ID card or MassHealth ID card to someone
- Misusing CeltiCare Health or MassHealth benefits
- Billing CeltiCare Health for “free” services
- Wrongful billing to CeltiCare Health by a Provider
- Billing CeltiCare Health for services not provided
- Any action to defraud CeltiCare Health, MassHealth, or the CarePlus program
CeltiCare Health is serious about finding and reporting Fraud and Abuse. Our staff is available to talk to you about this. If you know another CeltiCare Health Member or another person trying to commit healthcare Fraud, please write to the Fraud and Abuse Coordinator in CeltiCare Health's Compliance Department at:
200 West Street, Suite 250
Waltham, MA 02451
Your healthcare benefits are given to you based on your Eligibility for both MassHealth and the CarePlus program. You must not share your benefits with anyone. CeltiCare Health's Network Providers must report any misuse of benefits to CeltiCare Health. And CeltiCare Health must report any misuse or wrongful use of benefits to MassHealth. If you misuse your benefits, you could lose them.
If you think a healthcare Provider, doctor, or a hospital is misusing MassHealth or CeltiCare Health resources, tell us right away. We will forward any Provider issues to MassHealth for action. CeltiCare Health will take your call about waste, Fraud and Abuse seriously. Call CeltiCare Health's FAP Hotline at 1-866-685-8664. You do not need to give your name.
To report waste, abuse, or fraud, gather as much information as possible.
When reporting about a provider (a 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 gets 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