Reporting Fraud, Waste and Abuse
Western Sky Community Care is serious about finding and reporting times that New Mexico Medicaid funds are used in the wrong way. This is called waste, fraud or abuse.
What is Fraud?
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 health care fraud include:
- A lie on an application
- Using someone else's ID card
- A provider (doctor) billing for services that were not done
- Transportation (usage abuse)
What is Waste?
Waste is the overuse of services that may result in costs not needed for health care benefits. This includes direct costs and indirect costs. Waste usually results from the misuse of services.
What is Abuse?
Abuse is actions that may result in unnecessary costs not needed for health care benefits. This includes direct costs and indirect costs. Abuse involves payment for items or services when there is no legal reason for to pay for them.
What can you do about health care fraud?
If you think a provider, member or other person is misusing state or federally funded benefits, please tell us right away. We will take your call seriously.
To report potential fraud, waste, or abuse to Western Sky Community Care, please contact us right way. You do not need to give your name.
- Call Member Services at 1-844-543-8996 (TTY: 711)
- Send us an email.
To report potential Fraud, Waste or Abuse directly to the New Mexico Human Services Department, please use one of the methods below.
- Phone: 1-800-228-4802
- Fax: 1-505-797-5127
- Email New Mexico Human Services
- Or write to:
New Mexico Human Services Department
Office of Inspector General
8909 Adams St.NE, Suite A
Albuquerque, NM 87113
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