Fraud and Abuse Prevention

Our mission is to protect the overall integrity of the healthcare system, as well as to protect our members, providers, partners, and stakeholders, by reducing fraud, abuse, waste and mismanagement through timely and effective investigations. Everyone is responsible to make a difference.

How to report

Please note that all fraud, waste and abuse referrals are confidential and can be made anonymously.

Additional resources

Mission Statement

Our mission is to protect subscriber premiums by reducing fraud, abuse, waste and mismanagement through timely and effective investigations and, if appropriate, prosecutions and/or civil recoveries of instances of fraud, abuse and waste of health care dollars on a prospective and retrospective basis.

About Us

The Special Investigations Unit has been in existence since 1990, long before insurance companies were required to have a Special Investigations Unit. The main function of the Special Investigations Unit is to investigate allegations of fraudulent, abusive and wasteful billing practices. The staff includes an accredited health care fraud investigator, certified professional Coders, an accredited health information technologist, registered nurses and staff members with expertise in all aspects of health insurance.

The Unit is a member of the National Health Care Anti-Fraud Association, which provides current information on legislation, fraud trends and schemes and provides continuing education for all staff members.

Fabrication of Claims

A person uses real patient names and insurance information to make up entirely false claims or adds false charges for treatments or services that were never rendered to otherwise legitimate claims.

Examples include (but are not limited to):

  • A physician who creates claims for office visits/treatments that never took place.
  • A physician who routinely adds charges for services, such as X-rays or laboratory tests that were never performed.

Falsification of Claims

A person deliberately misstates one or more pieces of information on a claim for the purpose of receiving a payment (or higher payment) to which he/she is not entitled.

Examples include (but are not limited to):

  • Misstating patients' symptoms or diagnoses and/or the procedures performed, to obtain payment for otherwise non-covered services (cosmetic surgeries, 'alternative' therapies) and/or performing medically unnecessary services for the purpose of being paid for those services.
  • Falsifying the service dates so it appears the service was rendered while the patient was covered by insurance.
  • Falsifying the identity of the provider of services, to obtain payment for services rendered by a non-covered and/or non-licensed provider. Examples include (but are not limited to) billing fitness-center massages as licensed physical therapy, and billing non-covered weight-loss treatment as in-patient psychiatric treatment--e.g., for major depression.
  • 'Upcoding,' or falsifying the type of services provided, to obtain a higher payment. Examples include (but are not limited to) billing a 'Brief' initial office visit as a 'Moderate Complexity' office visit, and filling a prescription with the generic equivalent but billing for the higher-priced brand-name drug.
  • 'Unbundling,' or deliberately billing separate charges for numerous services for which there is one billing code and allowance.

In addition to investigations being performed in response to a customer complaint, we also rely on our internal staff to identify situations that may warrant further investigation. These include:

  • Inconsistency between the patient's diagnosis, history, and the billing records.
  • Provider's advertisement of 'free' services or prescriptions.
  • Provider's lack of supporting documentation for an audit.
  • Unusually high number of patients billed as new patients.
  • High-dollar claim for services rendered soon after effective date or just before termination of coverage.
  • Explanation of Benefits statement returned as 'undeliverable.'
  • Identity Theft (stolen health insurance identification card).
  • Allowing another person to use your health insurance identification card to obtain services.

The listing is not all-inclusive, nor does it suggest that fraud is committed in specific health care specialty areas. It is strictly intended to highlight the types of signals insurance companies and their investigative units will be sensitive to in their fraud-detection activities—either in the work of claims-review personnel or through computer-based analysis of claims and billing activity.

There is no such thing as 'free care.'

Ever see a newspaper ad promising your first exam is free? Is the exam really free? Or, will you be asked to provide your insurance information? If you did provide your insurance information on the day of your 'free exam,' you may be surprised to find that exam was paid for by your insurance company.

Never provide your insurance information over the phone.

Ever receive a telephone call from someone who inquires about your medical conditions? Has this person ever offered to send you a device to ease your pain? Did they ask for your doctor's name and telephone number, your insurance number? If you answered yes to any of these questions, you may have been the victim of fraud.

Never allow anyone into your home to test your hearing.

Has anyone telephoned you suggesting they come into your home to test your hearing? Were you told you needed hearing aids? Was the individual that tested you licensed by the State of New York? If not, your test results may not be correct. If you feel you have a hearing problem, speak to your doctor. Or, have your hearing tested by a licensed audiologist or otolaryngologist.

If your health insurance contract states you are responsible for a deductible and copayment, you ARE responsible for paying this portion of the fee.

Many health insurance contracts do not cover 'free care.' If you are responsible to pay a portion of your care, and, it's free to you, it's free to us. Since doctors are not in the business to give away care, you may find the doctor is charging your insurance more money than usual, just to make up for the portion you do not pay.

Providing erroneous or misleading information on a claim form, or submitting a claim with erroneous or fabricated information is considered insurance fraud.

Most states require you sign a claim form when submitting a bill for reimbursement. Usually, your signature will be directly beneath a statement that certifies the information stated on your claim form and the bills attached to it are accurate to the best of your knowledge. Your signature beneath this statement signifies you accept total responsibility for the claim submission.

Was your health insurance identification card stolen?

Someone using your identification card can have a direct effect on the services you receive. The imposter’s medical records may indicate that you have no allergies to any prescription drugs, when, in fact, you do. This could result in the administration of that drug, causing a reaction that can range from being mild to severe. Additionally, you may receive unnecessary treatment based on the imposter’s previous history.

The Special Investigations Unit has an ongoing relationship with the New York State Department of Financial Services. As required by Article IV of the insurance law, the Department of Financial Services is notified of all instances of suspected fraud. The Unit works closely with the department’s Criminal Division on these investigations.

The Unit also works directly with local district attorneys, the Medicaid Fraud Control Unit, the United States Attorney General’s offices and each entity’s investigative arms.

Medicare Part D regulations require all pharmacists and pharmacy staff who provide Part D covered services to receive appropriate Fraud Waste and Abuse (FWA) and Compliance Training, initially upon hire and at least annually thereafter.

Your Responsibilities:

  • Complete Fraud, Waste and Abuse (FWA) training program.
  • Maintain your own internal training logs.

We may ask to see the FWA training records when we conduct pharmacy audits in the future.

Your Training Options:

  • Provide your own training.
  • Complete training offered by another Medicare Advantage or Part D Plan Sponsor, or other CMS-approved training.

Learn more about Fraud, Waste and Abuse by viewing the CMS Prescription Drug Benefit Manual Chapter 9: Part D program to Control Fraud, Waste and Abuse.

 

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