Help us fight fraud

We are committed to our members, providers, and customers to be vigilant against suspected fraud. Although we believe that only a small percentage of people engage in fraudulent activities, the damage they do far exceeds their numbers. If ignored, fraud inflates the cost of healthcare and can undermine access to affordable healthcare coverage.

What is fraud?

Fraud is a crime of intentional deception or misrepresentation in which an individual or entity deceives an insurance company, usually to gain reimbursement or insurance benefits. Fraud can take place in many ways and may be committed by any party to healthcare delivery.

You can make a difference.

You can help us in our fight against fraud by being able to recognize signs of fraud and knowing how to report your suspicions. Providers can review claim forms prior to submission and subscribers/members can review the Explanation of Benefits (EOBs) (sent to members only if there is a patient co-payment responsibility) to ensure information is accurate and truthful.

Information to review:

• Name and address of the provider's office
• Date(s) of service
• Type and number of the procedure(s) provided
• Fees charged and the amount of co-payment that was collected
• Fraud leaves traces, and recognizing those traces requires the efforts of all of us.
   

Examples of fraudulent practices:

• Billing for services not provided
• Changing the date(s) of service to gain payment
• Inaccurate billing of services
• Waiving patient's co-payment and/or deductible
• Billing for a covered service when a non-covered service was performed
• Individuals who use someone else’s identification card
• Subscriber/members or provider offices that conceal other insurance coverage