Report Fraud, Waste and Abuse
Western Sky Community Care takes the detection, investigation, and prosecution of fraud and abuse very seriously, and has a fraud, waste, and abuse program that complies with the State of New Mexico and federal laws.
Western Sky Community Care in conjunction with its parent company, Centene, operates a fraud, waste, and abuse unit. Western Sky Community Care routinely conducts audits to ensure compliance with billing regulations.
Our sophisticated code editing software performs systematic audits during the claims payment process. To better understand this system, please review the Billing and Claims provider manual. The Centene Special Investigation Unit performs retrospective audits which, in some cases, may result in taking actions against providers who commit waste, abuse, and/or fraud.
These actions include but are not limited to:
- Remedial education and training to prevent the billing irregularity
- More stringent utilization review
- Recoupment of previously paid monies
- Termination of provider agreement or other contractual arrangement
- Civil and/or criminal prosecution
- Any other remedies available to rectify
Some of the most common fraud, waste, and abuse practices include:
- Unbundling of codes
- Up-coding services
- Add-on codes billed without primary CPT
- Diagnosis and/or procedure code not consistent with the member’s age/gender
- Use of exclusion codes
- Excessive use of units
- Misuse of Benefits
- Claims for services not rendered
How to report suspected Fraud, Waste, and Abuse
Potential Fraud, Waste or Abuse should be reported to the Western Sky Community Care anonymous and confidential hotline at 1-866-685-8664 or by contacting the health plan’s Compliance Officer at 1-844-543-8996 or email us.
To report potential Fraud, Waste or Abuse directly to the Human Services Department, please use one of the methods below.
- Phone: 1-800-228-4802
- Fax: 1-505-797-5127
- Email Human Services Department
- 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