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Healthcare Fraud, Waste & Abuse

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, or Abuse and stop it as soon as possible.

How YOU can help prevent Fraud, Waste, and Abuse

As our Member, you play an important role in helping us find Fraud, Waste, and Abuse. If you feel that Fraud, Waste, or Abuse might be happening, report it as soon as you can.


Here are some examples of possible Fraud:

  • Someone pretends to be from Highmark Wholecare, Medicare or Social Security and asks for your Social Security number, bank account or credit card numbers, money, etc.
  • 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.
  • You find out someone else is using your health insurance card.
  • You are billed for health care services or items you did not get.
  • Your doctor is ordering a lot of tests or items that you do not feel you need.

Review and identify the providers responsibilities as they relate to Fraud, Waste, and Abuse (“FWA”).

text reading fwa training with highmark wholecare

WATCH VIDEO
See disclaimer below 1

Provider Compliance Assessment Training

text reading welcome compliance assessment training with highmark wholecare

Highmark Wholecare’s Financial Investigations and Provider Review (FIPR) Division breaks down the purpose and value of the Provider Compliance Plan and how to complete the Provider Compliance Assessment, an integral part of an effective Compliance Plan.

WATCH VIDEO
See disclaimer below 1

VIEW OR DOWNLOAD 2024 PROVIDER COMPLIANCE ASSESSMENT TRAINING

VIEW OR DOWNLOAD FRAUD, WASTE AND ABUSE

VIEW OR DOWNLOAD 2024 PROVIDER FRAUD, WASTE AND ABUSE TRAINING

VIEW OR DOWNLOAD LAWS AND REGULATIONS

VIEW OR DOWNLOAD FRAUD AND PREVENTION AND DETECTION PLAN

VIEW OR DOWNLOAD 2023 PROVIDER TRAINING ON DMEPOS

VIEW OR DOWNLOAD AUDIT PLAN SUPPLEMENTAL GUIDE

If you suspect Fraud, Waste, or Abuse, call us at 1-844-718-6400 (TTY Users can call 711 or 1-800-654-5984) so we may look into your concerns. You can also use the online form to report suspected Fraud, Waste, or Abuse.

To report Medicare or Medicaid Fraud or Abuse you may contact Highmark Wholecare by mail or phone at:

Delivery Code: FIPR
Highmark Wholecare
Attn: FWA/SIU Unit
120 Fifth Ave
Pittsburgh, PA 15222

Or call the Fraud Hotline at: 1-844-718-6400

You may also report to the Pennsylvania Department of Human Services (DHS) at:

Department of Human Services
Office of Administration
Bureau of Program Integrity
P.O. Box 2675
Harrisburg, PA 17105-2675

Or call 1-866-DHS-TIPS (1-866-379-8477)

You have the option to remain anonymous at all times. You do not have to give your name. Highmark Wholecare has a team of people who look into all calls or mail regarding possible Fraud, Waste, or Abuse of health care services.

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