Fraud, Waste and Abuse

You Can Help Prevent Health Care Fraud, Waste, and Abuse

Guided by the highest standards of ethics as a federal government contractor, Gold Kidney is committed to create a safe culture of compliance. We have a strong commitment to members like you.

You Can Help Prevent Health Care Fraud, Waste, and Abuse

Millions are lost from health care fraud every day!

The National Health Care Anti-Fraud Association (NHCAA) estimates that daily losses total about $100 million. The impact of these losses and risks magnifies as Medicare continues to serve a growing number of beneficiaries.

You can help Gold Kidney Health Plan prevent, detect, and correct health care fraud by reporting suspicious activity. Help make our health care system better by reporting situations that may be potential health care Fraud, Waste, and Abuse (FWA).

What is Fraud, Waste and Abuse (FWA)?

Fraud is an intentional misrepresentation that may result in unauthorized costs to a healthcare program.

Waste is the inappropriate use of healthcare funds or resources without a justifiable need to do so.

Abuse is a practice that is inconsistent with sound medical or business practices that may directly or indirectly result in unnecessary costs to a healthcare program.

There are differences between Fraud, Waste, and Abuse. These differences are based upon intent and knowledge. Fraud requires the person to have an intent to obtain payment and the knowledge that their actions are wrong. Waste and Abuse may involve obtaining an improper payment but does not require the same intent and knowledge.

We expect everyone to report potential non-compliance including employees, contractors, and first-tier, downstream and related entities (FDRs). We’ve adopted and enforced a zero-tolerance policy for retaliation or intimidation against anyone who reports suspected misconduct. You may also choose to remain anonymous. If you are an FDR and you use your own code of conduct or compliance policies, you must include a process for reporting FWA issues that impact Gold Kidney.

Health care fraud, waste and abuse can take many forms, which makes it hard to spot. Here is a breakdown of the most common types.



  • Billing for service not rendered
  • Falsifying a patients diagnosis to justify unnecessary procedures
  • Accepting kickbacks for patient referrals


  • Ordering excessive diagnostic tests
  • Overuse of office visits
  • A pharmacy sending medications to members without confirming they still need them


  • Charging in excess for services or supplies
  • Providing medically unnecessary services
  • Going to different doctors or emergency rooms to obtain pain medication
Report Potential Fraud, Waste and Abuse (FWA)

You are our best ally when it comes to preventing health care FWA. If you suspect an incident is FWA, you have several ways to report it.

Reminder, you will always have the option to submit an anonymous report.

To Report FWA you can call Gold Kidney Health Plan’s COMPLIANCE HOTLINE at 1-844-974-5081

Or online at

Mobile site: