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Fraud, Waste and Abuse (FWA) - Chapter 16, 2018 UnitedHealthcare Administrative Guide

The purpose of our FWA program is to protect the ethical and fiscal integrity of our health care benefit plans and programs. Our program has two main functions:

  • UnitedHealthcare Payment Integrity, Optum entities, and others perform our payment integrity functions to help:
    • Ensure reimbursement accuracy
    • Keep up to date on new and emerging FWA schemes
    • Discover methodologies and technologies to combat FWA
  • Special Investigations Units (SIUs) perform prospective and retrospective investigations of suspected FWA committed against our benefit plans and programs.

This program is part of our Compliance Program led by our Chief Compliance Officer. Our Compliance Department works closely with internal business partners in developing, implementing and maintaining the program.

For definitions of fraud, waste, or abuse, please refer to the Glossary at the back of this guide.

If you identify compliance issues and/or potential FWA, report it to us immediately so we can investigate and respond appropriately. Please see the Resources and How to Contact Us section in Chapter 1 for contact information. UnitedHealthcare prohibits any form of retaliation against you if you make a report in good faith.