Español Medicare Plans Members Providers Agents & Brokers OTC Quick Links Member Login Preventing Fraud, Waste and Abuse As part of our efforts to improve the healthcare system, Optimum HealthCare has made a commitment to detecting and preventing fraud, waste, and abuse. Success in this effort is essential to maintaining a healthcare system that is affordable for everyone. Optimum HealthCare is getting the word out about how physicians and other health care providers can help with fraud, waste, and abuse prevention. What is Fraud, Waste, and Abuse? Fraud is generally defined as making a false claim in an effort to receive payment. For example, fraud in the healthcare industry can involve: Billing for medical services that weren't ordered or provided Billing for durable medical equipment items that weren't ordered or provided Providing services or items a person doesn't need based on his or her medical history "Doctor shopping" – when a patient who may or may not have a legitimate physical ailment goes from doctor to doctor to obtain multiple prescriptions for narcotic painkillers To protect yourself from fraud, thoroughly review your Explanation of Benefits (EOB) after you receive healthcare services. If you see something that doesn't look right, you should report the situation right away. Learn more about how to identify Enrollment Fraud by watching this video: Look out for Enrollment Fraud Waste is generally defined as overusing services or a misuse of resources that result in unnecessary costs to the Medicare Program. Conducting excessive office visits or writing excessive prescriptions Prescribing more medications than necessary for the treatment of a specific condition Ordering excessive laboratory tests Abuse is generally defined as payment for items or services when payment is not legally allowed and the provider has not knowingly misled the Plan or Medicare. Billing for unnecessary medical services Billing for brand name drugs when generics are dispensed Charging excessively for services or supplies Misusing codes on a claim, such as up-coding or unbundling codes How to Report Fraud, Waste, and Abuse To report suspected fraud, waste, abuse, non-compliance or HIPAA violations anonymously, you can contact Optimum HealthCare in one of these ways: Hotline: English (888) 548-0094 Toll-Free Fax: (888) 548-0092 E-mail: ComplianceReporting@americas1stchoice.com Mailing Address: PO Box 152137, Tampa, FL 33684 EthicsPoint Web Portal: www.americas1stchoice.ethicspoint.com Any individual, entity, or group that is employed by or provides a service on behalf of Optimum HealthCare (including employees, subscribers, professional providers, employees of a provider, facilities, or billing companies) may be the subject of the complaint. You will receive a response to your complaint, unless you choose to remain anonymous. Corporate Integrity Agreement On May 11, 2017, Optimum Healthcare, Inc. executed its Corporate Integrity Agreement (CIA) with the Office of Inspector General (OIG) of the United States Department of Health and Human Services (HHS) to promote compliance with the statutes, regulations, and written directives of Medicare, Medicaid, and all other Federal health care programs (as defined in 42 U.S.C. § 1320a-7b (f)) (Federal health care program requirements). The full CIA can be found here Last updated 10/01/2021 Helpful Links CMS Model Electronic Complaint Form The Medicare Beneficiary Ombudsman Unable to view PDFs? Click here Benefits During Disasters and Catastrophic Events Click here for Multi-Language Interpreter Service Servicios de interpretación en varios idiomas (Multi-Language Insert) | (Inserción de varios idiomas) Section 1557 Notice of Non-Discrimination: English | Spanish Hours From October 1 to March 31, we are open 7 days a week from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, 8 a.m. to 8 p.m. EST. Telephone Toll Free 1-866-245-5360 TTY/TDD: 711 Mailing Address P.O. Box 151137 ATTN: Optimum Healthcare Tampa, FL 33684 Service Cities SERVING THE FOLLOWING AREAS IN FLORIDA: Brevard County Broward County Citrus County Charlotte County Collier County Hernando County Hillsborough County Indian River County Lake County Lee County Marion County Manatee County Martin County Orange County Osceola County Palm Beach County Pasco County Pinellas County Polk County Saint Lucie County Sarasota County Seminole County Sumter County Volusia County Website Disclaimer Optimum HealthCare, Inc. is an HMO with a Medicare contract and a contract with the state of Florida Medicaid program. Enrollment in Optimum HealthCare, Inc. depends on contract renewal. This Information is not a complete description of benefits. Call 1-866-245-5360 (TTY: 711) for more information. Medicare beneficiaries may also enroll in Optimum HealthCare through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. Every year, Medicare evaluates plans based on a 5-star rating system. Optimum Healthcare, Inc. has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Chronic Condition Special Needs Plan (C-SNP) through 2022 and a Dual Special Needs Plan (D-SNP) until 2024 based on a review Optimum Healthcare, Inc.’s Model of Care. Optimum HealthCare, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Optimum HealthCare, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Optimum HealthCare, Inc. konfòm ak lwa sou dwa sivil Federal ki aplikab yo e li pa fè diskriminasyon sou baz ras, koulè, peyi orijin, laj, enfimite oswa sèks. Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-245-5360 (TTY: 711). Kreyòl Ayisyen (French Creole): ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-245-5360 (TTY: 711). These materials may be made available in alternate formats (e.g., large print, Braille) to individuals with disabilities, upon request. RETURN TO TOP Toll Free 1-866-245-5360 TTY/TDD: 711 OTC Home | About Us | Careers | Contact | Privacy Policy H5594_Website | © 2021 Optimum HealthCare Inc.