Fraud Waste and Abuse for Providers


To report suspected fraud, waste or abuse, you may submit a Special Investigation Referral by completing the on-line form HERE

Fraud, Waste and Abuse

In an effort to improve the healthcare system, NextLevel Health takes the prevention, identification, investigation and remediation of fraud and abuse very seriously. Success in these efforts is essential to maintaining a healthcare system that controls costs to benefit our providers, Members and tax payers. NextLevel Health is dedicated to working closely with our healthcare providers and business partners to help with fraud, waste and abuse detection, correction and prevention.

What are Fraud, Waste and Abuse?

  • Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any healthcare 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 healthcare benefit program. (18 U.S.C. § 1347)
  • Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.
  • Abuse is payment for items or services when there is no legal entitlement to that payment and the individual or entity has not knowingly and/or intentionally misrepresented facts to obtain payment.

Fraud, Waste and Abuse Training

NextLevel Health requires all contracted healthcare providers and business partners to train their employees and those supporting them to meet certain contractual obligations. This includes:

  • Developing training on combating fraud, waste and abuse or using another training to meet that educational requirement.
  • Tracking the training.

Note: To assist your organization, NextLevel Health’s materials from the Code of Conduct and Compliance Policy documents referenced further down this page may be integrated within the fraud, waste and abuse training or used as supplemental material.

Code of Conduct

The NextLevel Health’s Code of Conduct can be found HERE. We invite contracted healthcare providers and business partners to review this information as soon as possible.

Compliance Policy

NextLevel Health’s Compliance policy emphasizes our strong commitment to conducting business ethically, with integrity and in compliance with applicable laws, regulations and requirements. NextLevel Health requires its contracted healthcare providers and business partners to uphold a similar commitment to ethical conduct and assure that they, their employees and downstream entities who support NextLevel Health, comply with the guiding principles outlined in this policy.

How to Report Fraud, Waste or Abuse

If you suspect fraud, waste or abuse, you must report it to NextLevel Health and we will investigate. Your actions may help improve the healthcare system and ensure that together we remain cost efficient.

To report suspected fraud, waste or abuse, you can contact NextLevel Health in one of these ways:

  • You may submit a Special Investigation Referral by completing the on-line form HERE.
  • Or you may contact us by:
    • Phone or Fax: 1-888-859-2690
    • E-mail: [email protected]
    • Mail: NextLevel Health, Special Investigation Unit, 224 S. Michigan, Suite 700, Chicago IL 60604

You have the option to remain anonymous. All information received or discovered by the Special Investigation Unit (SIU) will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information.

NextLevel Health takes all reports of potential fraud, waste and/or abuse very seriously and will investigate all reported issues.

SIU Process

Our investigation process will vary, depending on the situation and allegation. Our investigational steps may include the following:

  • Contact with various parties to gather information: This may include contacting members to get a better understanding of the situation or contacting referring or associated providers.
  • Requests for medical, dental or pharmacy records: We do this to validate that the records support the services billed. It’s important that the healthcare provider submits complete records as requested. We rely on this information to make a fair and appropriate decision.
  • Notification of suspected fraud and abuse to the Office of Inspector General and/or law enforcement, if applicable.

Most common coding and billing issues

NextLevel Health’s SIU utilizes tools and techniques that help find and prevent healthcare fraud. This fraud detection also allows us to review our claims for possible fraud before and after payment.

Some of the most common coding and billing issues are:

  • Billing for services not rendered
  • Billing for services at a frequency that indicates the provider is an outlier as compared with their peers
  • Billing for non-covered services using an incorrect CPT, HCPCS and/or Diagnosis code in order to have services covered
  • Billing for services that are actually performed by another provider
  • Up-coding
  • Modifier misuse, for example modifiers 25 and 59
  • Unbundling
  • Billing for more units than rendered
  • Lack of documentation in the records to support the services billed
  • Services performed by an unlicensed provider but billed under a licensed provider’s name
  • Alteration of records to get services covered

SIU Actions Taken

NextLevel Health’s Special Investigation Unit (SIU) performs back end audits and investigations which may result in taking appropriate actions against those who, individually or as a practice, commit fraud, waste and/or abuse, including but not limited to:

  • Remedial education and/or training to attempt to eliminate the egregious action
  • Increasingly stringent utilization review
  • Recoupment of previously paid monies from a provider/practice
  • Termination of provider agreement or other contractual arrangement
  • Civil and/or criminal prosecution
  • Any other remedies available to rectify the issue identified

To report suspected fraud, waste or abuse, you may submit a Special Investigation Referral by completing the on-line form HERE