• You are here:  Home
  > 
• Legal Information
 > 
• About Fraud
 > 
• Fighting Health Care Fraud

Fighting Health Care Fraud

Special Investigations Unit

Health care fraud is committed when someone intentionally submits, or causes someone else to submit, false or misleading information for use in determining the amount of health care benefits payable. That is a crime. Any person convicted of health care fraud faces imprisonment and substantial fines. Health care fraud could be committed by dishonest health care providers such as physicians, dentists, labs, and medical equipment suppliers or by plan members themselves.

Certainly, most health care providers and consumers are honest and ethical. Only a small percentage deliberately engages in acts of fraud. So, if you don't cheat, why should you care about health care fraud? Cheaters raise the cost of health care benefits for everybody.

It is estimated that losses due to fraud add $100 billion to the annual cost of health care in the United States. For most employers, fraud increases the cost of providing benefits to their employees and, therefore, their overall cost of doing business. That translates into higher premiums and out-of-pocket expenses as well as reduced benefits or coverage. Fraud can also impact the quality of care you receive. When dishonest providers put greed ahead of care, proper diagnosis and treatment may be ignored and patients may be put at risk solely to generate higher dollar claims.

• Billing for services not actually performed.
• Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary.
• Misrepresenting procedures performed to obtain payment for non-covered services, such as cosmetic surgery.
• "Upcoding" . billing for a more costly service than the one actually performed.
• "Unbundling" . billing each stage of a procedure as if it were a separate treatment.
• Accepting kickbacks for member referrals.
• Waiving member co-pays or deductibles and over-billing the insurance carrier or benefit plan.

• Filing claims for services or medications not received.
• Forging or altering bills or receipts.
• Using someone else's coverage or insurance card.

EmblemHealth has established a Special Investigations Unit (SIU) to investigate each instance of possible fraud. The SIU includes a staff of trained professionals who take a look at each allegation. The SIU works closely with all other departments of EmblemHealth as well as Federal, State, and local law enforcement agencies and regulatory bodies. EmblemHealth has also implemented a state of the art system produced by IBM. This Fraud and Abuse Management System gives the SIU even greater fraud detection capability.

• Ask numerous questions about the services you receive.
• Fill out, sign, and date one claim form at a time; never sign a blank.
• Question advertisements or promotions by providers that offer free tests, treatment or services, especially if you are required to provide insurance information.
• In general, be careful about disclosing your insurance information. Protect your EmblemHealth ID card. It represents your benefits.
• Compare your medical bills and your EmblemHealth Explanation of Benefits (EOB) with your records.
• Report suspected fraud to Special Investigations.

• Simply call the Special Investigations Unit
  Anti Fraud Hotline toll-free at 1-888-4KO-FRAUD



• Write to us:
  Special Investigations Unit
  EmblemHealth
  55 Water St.
  New York, NY 10041.



• Report fraud by email.

The National Health Care Anti-Fraud Association (NHCAA) represents the cooperative effort of private-sector health insurers and public-sector law enforcement agencies to improve the prevention, detection, investigation and prosecution of health care fraud. EmblemHealth plays a leadership role in this important organization. The NHCAA web site provides information on health care fraud such as:

• Guidelines to health care fraud
• Impact of fraud on U.S. health care spending
• Nature of health care fraud
• NHCAA educational programs

Centers for Medicare & Medicaid Services (CMS), the Federal agency that administers Medicare, has a web section with information about fraud schemes targeting citizens covered by Medicare. See how CMS is Fighting Fraud & Abuse.

The Federal Bureau of Investigation (FBI) web site contains information on various types of health care fraud, with tips on how you can avoid them.

EmblemHealth TOLL FREE HOTLINE 1-888-4KO-FRAUD