Lighthouse Guild’s patients, health plan members, employees, vendors and providers all have a legal obligation to be on guard for and immediately report any known or suspected fraud waste and abuse practices.
The following definitions and examples should be used as a reference guide to assist you in reporting a known or suspected instance(s) of fraud waste and/or abuse.
Fraud is intentional or misrepresentation of a fact/statement/document with the knowledge that the deception could result in some unauthorized benefit.
Example: A provider bills Medicaid or Medicare for services that were not rendered.
Example: A patient uses someone else’s Medicare or Medicaid card with or without their permission.
Waste is intentional, unintentional, careless or thoughtless behavior that results in overspending or demonstrates a misuse of resources without the intent to deceive or misrepresent.
Example: Prescribing more medications than necessary.
Abuse is the result of practices that are inconsistent, or outside the bounds of generally accepted practices in the industry, which result in unnecessary services and payment.
Example: Billing for unnecessary medical services.
Reporting a Compliance Concern or Fraud Waste & Abuse
Compliance Programs are most effective in organizations that encourage the reporting of suspected violations. Lighthouse Guild maintains anonymous and confidential methods for any party, including contractors to report a compliance concern or fraud waste and/or abuse practices:
Lighthouse Guild’s Anonymous Compliance Hotline:
800-283-4900 (24 hours a day/ 7 days a week)
Lighthouse Guild Compliance’s Confidential Email Inboxes:
Contact Lighthouse Guild’s Compliance Officer by mail:
ATTN: Compliance Officer
250 West 64th Street
New York, NY 10023