Fraud & Abuse

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Fraud, abuse and waste are widespread in the health care industry and generally result in the increase of health care costs. The health plan is dedicated to fight fraud, abuse and waste through its Fraud Prevention Program. This program is designed to detect and eliminate health care fraud, abuse and waste.

The most common types of health care fraud, abuse and waste are:

  • Billing for services never provided
  • Billing for more expensive services then were actually provided
  • Incorrectly stating a diagnosis to get higher payments
  • Performing unnecessary services to get higher payments
  • Misrepresenting non-covered procedures as medically necessary
  • Selling or sharing a member's identification number for the purpose of filing false claims

If you believe you have information relating to health care fraud, abuse and waste, please contact our Fraud Prevention Department. The Department will review the information provided and will maintain the highest level of confidentiality as permitted by law. Suspected acts of fraud, abuse and waste may be submitted by using our "Fraud, Abuse and Waste Referral Form".

You may prefer to contact our Fraud Prevention Department by calling 1-866-806-7020.

You can help support our mission to reduce and eliminate fraud in the health care industry by following a few simple guidelines:

  • Be careful when providing your health care information, including your member identification number. Be cautious of "free" medical treatments where you are required to provide them with your health care information.
  • Read your Explanation of Benefits (EOB) carefully. Make sure the services described on the EOB are the same services you received by the doctor.
  • Understand your benefit plan and what types of treatments, drugs, services, etc., are covered.

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