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Report Fraud and Abuse

Fraud Hotline: 800-372-8321

Report Fraud and Abuse

What is healthcare fraud, and why is it a problem?

Fraud occurs when a dishonest member or provider lies on an application or claim form with the intention of receiving a payment from Health Advantage to which they are not entitled.

As stated in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (18USC, Ch. 63, Sec 1347):

Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice to defraud any healthcare benefit program; or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any healthcare benefit program, in connection with the delivery of or payment for healthcare services, shall be fined under this title or imprisoned not more than 10 years or both.

Fraud and abuse is estimated to account for between 3 and 10 percent of the annual expenditures for healthcare in the United States.

What are common types of fraud?

  • Providing false statements on an application
  • Submitting claims for services that were not performed
  • Misrepresenting services that were provided
  • Providing medically unnecessary services

What are the penalties for committing healthcare fraud?

Healthcare fraud is both a state and federal offense. As stated in the HIPAA Act of 1996: (18USC, Ch. 63, Sec 1347), a dishonest provider or member is subject to fines or imprisonment of not more than 10 years or both. Making false or misleading statements on an application carries a maximum five-year sentence.

You can help!

Read your Personal Health Statement (PHS) or Explanation of Benefits (EOB) carefully. This document is your notification that we have paid a claim under your healthcare benefits plan. Look for:

  • Incorrect dates of service
  • Services that you did not receive
  • Non-laboratory or non-X-ray providers that did not see or treat you

Fraud Hotline

Call the Fraud Hotline at 800-372-8321 any time day or night. All tips are kept strictly confidential.

Special Investigations Unit - Mission Statement

The detection, prevention and elimination of fraud, abuse and over-utilization are essential to maintaining a healthcare system that is affordable for everyone now and in the future.

We aggressively investigate and pursue the prosecution of the perpetrators of healthcare fraud, abuse and over-utilization, including providers of medical and other related health services, agents, members and others.

We actively cooperate with criminal investigations conducted by federal, state and local authorities, encourage education and conduct awareness programs to alert our employees, members and the general public to potential fraud or abuse.