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  • Fraud, Waste and Abuse

  • Definition of Fraud, Waste and Abuse:

    Any type of intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person in a managed care setting, including any act that constitutes fraud under applicable federal or state law, committed by an MCO, contractor, subcontractor, provider, beneficiary or enrollee or other person(s). Fraud also includes knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program.

    The overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program, Medicaid program, or Affinity. Waste is generally the misuse of resources.

    Provider practices that are inconsistent with sound fiscal, business or medical practices and result in an unnecessary cost to the state or federal government or MCO, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care in a managed care setting, committed by an MCO, contractor, subcontractor, provider, beneficiary or enrollee. Abuse also includes enrollee practices that result in unnecessary cost to the state or federal government, MCO, contractor, subcontractor or provider.

    Relevant Laws Pertaining to Compliance, Including Fraud, Waste and Abuse

    • Federal False Claims Act
    • The Deficit Reduction Act
    • New York State False Claims Act
    • Federal Anti-Kickback Statute
    • Federal Stark Law
    • Health Insurance Portability and Accountability Act (HIPAA)
    • Health Information Technology for Economic and Clinical Health (HITECH) Act

    Refer to Federal and State resources for more information pertaining to these laws and other regulatory requirements.

    Protection for Reporters of Compliance Concerns, Including Fraud, Waste or Abuse

    Federal and state law and Affinity’s policy prohibit any retaliation or retribution against persons who report suspected violations of these laws to law enforcement officials or who file “whistleblower” lawsuits on behalf of the government. Anyone who believes that he or she has been subject to any such retribution or retaliation should also report this to our Compliance Department.

    A Roadmap to Avoid Fraud, Waste and Abuse

    The Office of the Inspector General (OIG) has created free materials for Providers to assist you in understanding the federal laws designed to protect Medicaid and Medicare programs and program beneficiaries from fraud and abuse. This brochure can be found on the Office of Inspector General’s website.

    How to Report a Compliance Concern, Including Fraud, Waste or Abuse

    It is Affinity’s policy to detect and prevent any activity that may constitute a compliance concern including fraud, waste, or abuse. This includes violations of the federal False Claims Act or any federal or state Medicare or Medicare fraud laws. If you have knowledge or information that any such activity may be or has taken place, please contact our Compliance Department.

    Reporting of a compliance concern including potential or actual fraud, waste, or abuse can be anonymous.

    Options for reporting anonymously:

    • Call Affinity’s Ethics Line at 866.528.1505 and follow the appropriate menu option
    • Visit the Ethics Line site
    • Send a written report to:
      Affinity Health Plan
      Attn: Compliance
      Metro Center Atrium
      1776 Eastchester Road
      Bronx, NY 10461

    Options for reporting that are not anonymous:

    • Call 866.247.5678 and ask for the Compliance Officer or Compliance Director
    • Email a report to
    • Fax a report to 718.536.3391

    NOTE: When reporting a compliance concern including potential or actual fraud, waste or abuse, please give as many details as you can, including names and phone numbers. You may remain anonymous, but if you do we will not be able to call you back for more information. Your reports will be kept confidential to the extent permitted by law. Thank you for helping Affinity keep fraud, waste and abuse out of health care.

    If you have any questions or need additional information, please call us at 866.247.5678.