Report Fraud, Waste and Abuse

SilverSummit Healthplan 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 Nevada and federal laws.

SilverSummit Healthplan, in conjunction with its parent company, Centene, operates a fraud, waste, and abuse unit. SilverSummit Healthplan 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 FWA 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

Potential Fraud, Waste or Abuse should be reported to SilverSummit Healthplan’s anonymous and confidential hotline at 1-866-685-8664 or by contacting the health plan’s Compliance Officer at 1-844-366-2880 or ReportFWA@silversummithealthplan.com.  

 

How to report suspected Fraud, Waste, and Abuse

If you suspect that Medicaid Fraud may be occurring, complete and submit the form and mail it to the Office of the Attorney General, Medicaid Fraud Control Unit, 100 North Carson Street, Carson City, NV 89701. You can also call the Nevada Medicaid Fraud Control Unit at 775-684-1100 or 702-486-3420.