Fraud, Waste and Abuse |

Fraud, Waste and Abuse


You Can Make a Difference. Report Suspected Fraud.

Did You Know?

  • Health care fraud is contributing to the rising cost of health insurance.
  • Health care fraud reduces the amount of funds available to pay honest providers.
  • Health care fraud increases premiums to employers and members.
  • We will investigate allegations of fraud, waste and abuse – and reports of non-compliance on any level.
  • Our Special Investigations Unit is available as a resource to our employees, members and providers, as well as to our delegates – first tier, downstream, and related entities.
  • See below for examples of fraud and more.

Fraud:

Intentional deception or misrepresentation to obtain the money or property of a health care benefit program (by means of false or fraudulent pretenses, representations, or promises).

  • Some examples of consumer health care fraud:
    • filing claims for services or medications not received
    • forging or altering bills or receipts
    • using someone else's coverage or insurance card

  • Some examples of provider health care fraud:
    • billing for services not actually performed
    • falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary
    • upcoding – billing for a more costly service than the one actually performed

  • Some examples of non-compliance:
    • theft or unauthorized removal of company/business documents from the premises
    • falsifying or tampering with company documents or records
    • violations of our company's Code of Conduct
    • insubordination, dishonesty, gross carelessness/negligence of duties

Waste: 

The over-utilization of services or other practices that result in unnecessary costs.

  • Some examples of Waste are: 
    • making excessive office visits or ordering excessive laboratory testing

Abuse: 

Obtaining payment for items or services when there is no legal entitlement to that payment, but without knowing and/or intentional misrepresentation of facts to obtain payments.

  • Some examples of Abuse are: 
    • billing for services that were not medically necessary 
    • charging excessively for services or supplies 
    • misusing codes on a claim, such as up-coding or unbundling services

To report potential fraud, waste and abuse in the Medicare program, please use one of the following applicable channels:

  • Our Fraud hotline and Integrity hotline are available 24/7, and callers may choose to remain anonymous.
  • Medicare Fraud Hotline of the HHS office of Inspector General:

What to include in your report:

  1. Unless you choose to remain anonymous, please provide your name, telephone number, address, and email address. If you are submitting your report anonymously, please take care to withhold personally identifiable information.
  2. Explain the nature, scope and time frame of the activity in question.
  3. Explain how you are aware of the alleged activity.
  4. Specify if you know of any potential witnesses to the activity.
  5. Provide any documents or other physical evidence in your possession.

  • Miami, Tampa and Orlando, Florida
  • Los Angeles, California
  • Detroit, Michigan
  • Dallas, San Antonio and Houston, Texas
  • Brooklyn, New York
  • Baton Rouge and New Orleans, Louisiana
  • Chicago, Illinois
  • Ft. Mitchell, Kentucky
  • Nashville, Tennessee
  • Newark, New Jersey/Philadelphia, Pennsylvania
  • Washington, D.C.

*As of Fiscal Year 2019, the Department of Health and Human Service Office of Inspector General and the Department of Justice identified these U.S. cities/regions as most at risk for high incidences of fraud, waste and abuse.