As your health insurance carrier, we encourage you to become an active participant in the fight against fraud in the healthcare industry by reporting suspicious activities related to medical and prescription drug coverage.
In accordance with state and federal laws, Health First Health Plans is required to establish and maintain a unit known as the Special Investigations Unit (SIU) to investigate suspicious activity. This internal unit is responsible for the detection, investigation and reporting of potential fraud and abuse activity within our organization.
Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true, and makes knowing that the deception could result in some unauthorized benefit to himself/herself or some other person.
The most common type of health insurance fraud involves a false statement, misrepresentation or deliberate omission that is critical to the determination of payable benefits. Fraud is a crime when an individual intentionally submits, or causes someone else to submit, false or misleading health information.
The some common healthcare fraudulent acts include, but are not limited to:
The National Health Care Anti-fraud Association (NHCAA) estimates that conservatively 3 percent of all health care spending is lost to health care fraud-estimated at $68 billion. Over time, this will result in:
By partnering together and increasing the awareness of healthcare fraud, waste, and abuse, we maximize our efforts to detect and pursue the harmful effects of such activity.
When reporting suspicious activity, be sure to include all relevant information. Specify which person you believe is committing the fraud, date(s) of when the issue occurred and provide details as to why you believe a fraudulent act may have occurred. Unless you choose to remain anonymous, please provide us your name and contact information so we may contact you with any additional questions during our investigation.
Report fraud using our online form.
Y0089_MP4370FH CMS Approved 11052014
Last updated: 10/01/2014