Complaints, Grievances, and Fraud, Waste, Abuse
Complaints & Grievances
Complaints and grievances can be raised by you, a family member or friend, your legal guardian, or authorized representative.
We encourage you to try to solve any issue with your service provider. You can try to discuss your concern with a staff member or a individual representative. Your service provider should give you written information about their grievance process, including time frames for conflict resolution.
In the event that the resolution from the provider is not satisfactory to you, and you have exhausted all the options for appeals at the provider level; you can present your concern to Central Florida Cares Health System, Inc (CFCHS).
Please keep in mind that because of HIPAA and confidentiality laws, CFCHS will only receive information related to funded individuals.
The following procedure will then take place:
- A CFCHS designee will get in touch with you.
- CFCHS will work with the service provider to find a resolution.
- Either CFCHS or the service provider will contact you to let you know of the outcome.
- If you are still in disagreement with the proposed resolution we will continue working with you and the provider to find a better outcome.
- You also have the right to contact the Department of Children and Families, Substance Abuse and Mental Health Program Office Central Region at (407) 867-0063.
Fraud, Waste, and Abuse
Central Florida Cares Health System, Inc. (CFCHS) promotes a culture of integrity and works with business partners, subcontractors, and employees to ensure compliance with standards of ethical practice and regulatory requirements. CFCHS investigates all allegations of Fraud, Waste and Abuse (FWA), takes corrective action of any supported allegations, and reports confirmed misconduct to the pertinent government entities.
If you suspect Fraud, Waste and Abuse, please take into consideration the following definitions:
Fraud: Any intentional deception or misrepresentation made by an entity or person with the knowledge that the deception could result in an unauthorized benefit for payment to the entity, him/herself or another person.
Waste: Refers to the irresponsible and careless expenditure, consumption, mismanagement, use, or squandering of healthcare resources, including incurring costs because of inefficient or ineffective practices systems or controls.
Abuse: Refers to practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards of care. It also includes individual practices that result in unnecessary cost.
Some FWA instances may involve:
• Contract Fraud and Mismanagement
• Conflict of Interest
• Misuse of Position or Property
• Improper use of Public Funds
• Violations of Law, Rule, or Procedure
• Inappropriate Acts and/or Omission that results in individual injury, abuse, neglect or death
To report a Complaint or Fraud, Waste, and Abuse:
• Dial toll-free, within the United States, Guam, Puerto Rico and Canada: 844-302-0433
• Submit an electronic report by clicking here http://centralfloridacares.ethicspoint.com
• You can also contact the Office of the Florida Inspector General at:
1317 Winewood Blvd., Bldg. 5, Second Floor
Tallahassee, FL 32399-0700
Phone: (850) 488-1225
Fax: (850) 488-1428