Prevention and Detection of Fraud Waste and Abuse

ArchCare Community Life (ACL) and ArchCare Senior Life (ASL) are Medicaid Managed Long Term Care Plans and are part of the Catholic Health Care System d/b/a ArchCare committed to a culture that promotes prevention, detection and remediation of Fraud Waste and Abuse (“FWA”). Accordingly, ArchCare maintains a robust Compliance Program to prevent, detect and remediate fraud, waste and abuse for all of its affiliated entities. The goal of the ArchCare FWA Program, as with the Compliance Program, is to promote understanding of and adherence to applicable laws and regulations and guidance and to make a sincere effort to prevent, detect, and resolve situations that do not conform to applicable regulatory requirements.

What is Fraud, Waste and Abuse?

Fraud includes obtaining a benefit through an intentional false statement, misrepresentation, or concealment of material facts. Fraud is defined as an intentional deception, false statement, or misrepresentation made by a person with the knowledge that the deception could result in unauthorized benefit to oneself or another person. It includes any act that constitutes fraud under applicable federal or state law. It is a crime to defraud the Federal Government and its programs.

Examples of Fraud

  • Providing false statements on an enrollment application to obtain coverage or concealing information about past medical history/preexisting conditions.
  • Using someone else’s ID card or loaning your ID card to someone not entitled to use it.
  • Failing to report other insurance or to disclose claims that were a result of a work related injury.
  • Billing for services that were not rendered.
  • Providing services that are not medically necessary for the purpose of maximizing reimbursement.
  • “Upcoding” – billing for a more costly service than was actually provided.
  • “Unbundling” – billing each step of a test or procedure as if it were separate instead of billing the test or procedure as a whole.
  • Submitting claims with false diagnoses to justify tests, surgeries or other procedures that are not medically necessary.
  • Accepting kickbacks for member referrals.
  • Fabricating claims.

Waste is spending that can be eliminated without reducing quality of care, i.e. deficient management, practices, or controls. Waste is defined as failure to control costs or regulated payment associated with federal program funding. Furthermore, waste results in taxpayers not receiving reasonable value for their money. Waste relates primarily to mismanagement, inappropriate actions, or inadequate oversight.

Examples of Waste

  • Poor execution or lack of widespread adoption of best practices, such as effective preventive care practices or patient safety best practices.
  • Overtreatment.
  • Unnecessary hospital readmissions, avoidable complications, and declines in functional status, especially for the chronically ill.
  • Administrative complexity.

Abuse includes excessively or improperly using government resources; providing substandard quality of care. Abuse is defined as practices that are inconsistent with professional standards of care; medical necessity; or sound fiscal, business, or medical practices.

Examples of Abuse

  • Billing for services that were not medically necessary.
  • Charging excessively for services or supplies.

What should you do if you suspect or have knowledge of Fraud, Waste and/or Abuse?

All ArchCare employees, subcontractors and vendors are required to report concerns about actual, potential or perceived misconduct to the ArchCare Compliance Department.

How can you report of Fraud, Waste and Abuse, and Return an Overpayment?

Anyone can make a report including employees, affiliated medical and allied professional staff, contractors, subcontractors, agents and independent contractors and recipients of services.

ArchCare Chief Compliance Officer: 1-646-633-4401
ArchCare Compliance Hotline: 1-800-443-0463
ArchCare Compliance online portal: 
24 hours, 7 days a week
Without worry of retaliation or intimidation, if reporting in good faith

ArchCare has established a Special Investigations Unit (“SIU”) to investigate reports of FWA as they related to ACL and ASL.   The SIU works to identify FWA schemes. For more information please refer to ArchCare FWA Detection Manual.

Our policies and procedures require that our Medicaid business partners/vendors complete and submit the ArchCare Annual Compliance Attestation, and implement all activities described in the attestation. 

View CMS Fraud, Waste and Abuse Training

Special Investigation Unit Policy

View Provider ArchCare Compliance Fraud, Waste and Abuse Training and Attestation

Medicare Fraud

Protecting Medicare and You From Fraud

Other Useful Links:

The Office of Inspector General:
The Centers for Medicare and Medicaid Services (CMS):