Report Fraud, Waste and Abuse

Arkansas Health & Wellness takes the detection, investigation, and prosecution of fraud and abuse very seriously, and has a WAF program that complies with Arkansas and federal laws. Arkansas Health & Wellness, in conjunction with Centene, successfully operates a WAF unit. Arkansas Health & Wellness performs front and back end 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 section of this manual. Centene’s Special Investigation Unit (SIU) performs back end audits which in some cases may result in taking the appropriate actions against those who, individually or as a practice, commit waste, abuse, and/or fraud, including but not limited to:

  • Remedial education and/or training around eliminating the egregious action
  • 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 WAF submissions seen are:

  • Unbundling of codes
  • Up-coding
  • Add-on codes without primary CPT
  • Diagnosis and/or procedure code not consistent with the member’s age and/or gender
  • Use of exclusion codes
  • Excessive use of units
  • Misuse of benefits
  • Claims for services not rendered

If you suspect or witness a provider inappropriately billing or a member receiving inappropriate services, please call our anonymous and confidential hotline at 1-800-294-3557. Arkansas Health & Wellness and Centene take all reports of potential WAF very seriously and investigate all reported issues.