Fraud, Waste, and Abuse

Quick Links for Fraud Waste and Abuse

What is Fraud, Waste, and Abuse?

Fraud is any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself, herself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

 

Waste involves the taxpayers not receiving reasonable value for money in connection with any government funded activities due to inappropriate act or omission by player with control over, or access to, government resources.

 

Abuse is any provider practices that are inconsistent with sound fiscal, business, or medical practices, and result either in an unnecessary cost to the federally-funded programs or in reimbursement for services that are not medically necessary or provider practices that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the federally funded programs.

 

Fraud, waste, and abuse hurts everyone.

It can even raise the cost of getting health care services. This is why we need help from our members and providers to find fraud, waste, and abuse and stop it as soon as possible. As our member, you play an important role in helping us find fraud, waste, and abuse. If you feel that it might be happening, report it as soon as you can. Here are some examples of possible fraud:

 

  • A health care provider offers you cash or gifts to get free medical care.
  • A pharmacy bills you for drugs you did not get, or the pharmacy did not give you the right number of pills ordered by your doctor.
  • Someone pretends to be from Highmark Health Options and asks for your Social Security number, bank account or credit card numbers, money, etc.
  • You are billed for health care services or items you did not get.
  • Your doctor orders a lot of tests or items that you do not feel you need.
  • You find out someone else is using your health insurance card.

 

Learn About Payment Integrity 

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Fraud and Abuse Laws and Regulations

General Information - Provides monetary penalties that can be imposed upon a health care provider for knowingly and willfully making false statements or representations in connection with filing a claim seeking reimbursement from a federally funded health care program. In this act, the definition of “knowingly” includes actual knowledge, deliberate ignorance and reckless disregard for the truth. Some examples of health care fraud have included: certifications and information, lack of medical necessity, duplicate claims for the same service, submitting claims for an excluded provider, inserting diagnosis codes not obtained from a physician or other authorized individual, etc. There is often some falsification of records to support improper billings.

 

Potential Penalties

  • Fines up to $11,000 per services billed and/or three times the amount originally billed and/or
  • Exclusion from Medicare, Medicaid, and other federally funded health care programs

 

False Claims Act Whistleblower Employee Protection

While Highmark Health Options believes it has confidential reporting and investigative processes in place, employees may consider pursuing under the anti-retaliatory provisions or the False Claims Act contained in 31 U.S.C Sec 3730 (h). These provisions protect workers from retaliation or other illegal treatment and provide ways to recover a share of monetary damages if such damages are awarded to the Federal Government if/when a lawsuit is settled.

General Information - Provides civil and criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit or receive “remuneration” to induce the referral of business. Examples of “remuneration” include services (such as free testing or supplies) as well as items (such as cash, equipment, software, gifts, and other things of value). No bribes, kickbacks or other inappropriate payments should be offered or given to any person or entity for any reason including, but not limited to, the acquisition or retention of business.

 

Potential Penalties

 

  • Imprisonment up to 5 years and/or
  • Criminal and civil fines up to $25,000 and/or
  • Exclusion from the Medicare, Medicaid, and other federally funded health care programs

 

General Information - Provides criminal penalties for individuals or entities that do not adhere to the regulations regarding financial arrangements between referring physicians (or a member of the physician’s immediate family) and entities that provided designated health services payable by Medicare or Medicaid. In contrast to the anti-kickback statute, it does not require any showing of the “wrongdoer’s” intent. Penalties can be applied if an arrangement exists that does not satisfy allowed exceptions.

 

Potential Penalties

  • Civil money penalty of $15,000 per service billed
  • Civil money penalty of $100,000 and exclusion for arrangements or schemes to circumvent the statute
  • Exclusion from the Medicare, Medicaid, and other federally funded health care programs and/or
  • Refund of amounts collected in violation of the statute

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Report Fraud, Waste and Abuse

Do you suspect fraud, waste, and abuse?

We have a team of people who look into all calls or mail regarding possible fraud, waste, and abuse of health care services. You do not have to share your name when making a report. Tell us of suspected fraud, waste, and abuse of services paid for by Highmark Health Options.

Report Medicaid fraud, waste, and abuse by contacting Highmark Health Options through mail, email, or phone. You can also use the secure online form below.

Report by Mail

To report Fraud, Waste and Abuse by mail, please send your report to:

Highmark Health Options 
HHOFRAUD 
120 Fifth Avenue 
Pittsburgh, PA 15222

Report by Phone

To report Fraud, Waste and Abuse by phone, call  1-844-325-6256.

Report by Email

To report Fraud, Waste and Abuse electronically, send us an email message SIU_HHO@highmark.com.


 

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Report Through Secure Form

Use the secure form to share information about the suspected member or provider. This form is to tell us of suspected fraud, waste, and abuse of services paid for by Highmark Health Options. Fill in as much of the information as you can, then click the submit button. 

*Required Please enter your first name
*Required
*Required Please enter your last name
*Required Please enter your phone number

Describe the event that may be fraud, waste, and abuse.

Describe the event that may be fraud, waste, and abuse. Give details about when the event happened and the people involved. Some examples of details are: billing for services you did not receive or someone using your identity to receive medical services. 

*Required

How can we contact you?

Provide your contact information so we can contact you is we have questions. Your identity will be protected to the extent allowed. Thank you for helping Highmark Health Option’s efforts to find fraud, waste, and abuse.

*Required Please enter your first name
*Required Please enter your phone number
*Required Please enter your last name

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Keep Track of Your Health Services

When you get health care services, record the dates on a calendar and save the receipts and statements you get from your doctor to check for mistakes. You should keep track of these things:

  • The date of your health care visit.
  • What services you got during the visit and any tests or visits the doctor ordered.
  • Where the health care visit took place.
  • Who provided your health care.

 

Keeping track of your health services will not only help you to improve your health, but it will also help you to know when there is a problem such as fraud. Ways to protect yourself from fraud, waste, and abuse:

  • Call Highmark Health Options as soon as possible if your health insurance card is stolen.
  • Check all bills, statements, or health care information you get. Make sure that the information is correct. If something does not look right, call us as soon as possible so we can look into it.
  • Do not give your health insurance card or card numbers to anyone other than your doctor, clinic, hospital or other health care provider.
  • Do not share your medical records with anyone other than your doctor, clinic, hospital or other health care provider.
  • Do not sign your name to any health care forms that are blank.

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Additional Resources

Medicare/Medicaid Fraud, Waste, and Abuse Training 

See disclaimer below1

Curso de formación sobre fraude, derroche y abuso de Medicare/Medicaid

See disclaimer below1

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1By accessing this video, I understand that I am leaving the Highmark Health Options website. I will be redirected to an external website operated by a third party. I acknowledge that the third party may collect personal information about me and about the video I watch on their platform. The third party may use and disclose this information in accordance with its privacy policy. I agree that Highmark Health Options is not responsible for the data collection and use practices of this third party.