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Medicaid Open Enrollment begins October 1st. To join Delaware First Health, call the Health Benefits Manager at 1-800-996-9969
Medicaid Open Enrollment begins October 1st. To join Delaware First Health, call the Health Benefits Manager at 1-800-996-9969

Report Fraud, Waste and Abuse

Delaware First Health 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 Delaware and federal laws.

Delaware First Health in conjunction with its parent company, Centene, operates a fraud, waste, and abuse unit. Delaware First Health 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 Delaware First Health anonymous and confidential hotline at 866-685-8664 or by contacting the health plan’s Compliance Officer at 314-445-0175 or contact us.

To report potential Fraud, Waste or Abuse directly to the Delaware Department of Health and Social Services, please contact the Diamond State Health Plan Helpline at 800-372-2022.

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