Your Role in Prevention
As our clients’ members and providers, you play an essential role in finding and preventing potential fraudulent or abusive behavior and practices. We encourage you to report any matters you suspect may involve fraud or abuse. All contact information and anything reported is kept strictly confidential.
Defining Fraud and Abuse
Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to them or some other person.
Abuse means provider practices that are poor business or medical practices, and/or result in an unnecessary cost to your benefit program. This can include reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. It also includes member behaviors that may result in unnecessary cost to the program.
We investigate cases of suspected fraud and abuse through a comprehensive review process. All findings are submitted for further investigation, determination, and action to state regulators and law enforcement agencies as required.
How to Report Fraud and Abuse Confidentially
You can report suspected fraud or abuse by phone, through email, or by regular mail. You may do this anonymously, but if you agree to provide your name and other contact information, it will assist our Fraud and Abuse Department in completing a full, comprehensive review. All contact information and reports are kept strictly confidential.
When reporting suspected fraud or abuse, please provide as much detail as possible, including:
- The name of the doctor, hospital, or other healthcare provider you suspect of committing fraud and/or abuse
- Place of service
- The date(s) of service
- A description of the act that you believe may have involved fraud and/or abuse
- The amount of money that may be involved, if you know