EmblemHealth Health Care Fraud Detection

EmblemHealth's Special Investigations Unit (SIU) strives to prevent fraud and abuse.

EmblemHealth employs IBM's Fraud and Abuse Management System (FAMS), a state of the art software package that improves methods of detection and investigation. FAMS provides the SIU with a unique tool in its efforts to reduce financial losses due to fraud and abuse.

FAMS compiles claims data and ranks providers against peers in the same specialty groups. The SIU reviews provider billings and scores the data, creating a "report card" which identifies providers who fall outside the norms of their peer groups. For example, the report cards readily identify providers who routinely use more testing than others or treat more patients on non-work days. FAMS also helps the SIU to uncover member fraud and abuse by identifying suspicious behaviors in member histories.

This software gives the SIU instantaneous access to claims information that once took weeks to compile, resulting in more aggressive and efficient investigations.

The message is clear: providers and members who operate on less than honorable levels will not be successful at EmblemHealth!

SIU Red Flags

If you suspect fraud — Call the SIU Hotline - 1 888-4KO-FRAUD

BE SUSPICIOUS IF SOMEONE SAYS:

  • "I represent EmblemHealth" without a valid reason for calling.
  • "The service/equipment is free."
  • "I need your EmblemHealth ID number," or your Social Security number.
  • "I will pay you if you give me/let me use your EmblemHealth number."
  • "I will pay you to visit my office."
  • "I know how to get EmblemHealth to pay for it."
  • "EmblemHealth wants you to have this."
  • "The more tests we provide the cheaper they are."

ALSO BE SUSPICIOUS IF SOMEONE:

  • Routinely waives copayments without checking on your ability to pay.
  • Advertises "free" consultations.
  • Shows up at the front door or calls on the phone to market EmblemHealth related services or products.
  • Bills EmblemHealth for services you don't recall receiving.

UNLAWFUL ACTIVITIES INCLUDE:

  • Billing more than once for the same service or product.
  • Misrepresenting the services rendered.
  • Misrepresenting a diagnosis to justify payment for services.
  • Misrepresenting the place of service.
  • Altering EmblemHealth claim forms to get a higher payment.
  • Falsifying documents.
  • Soliciting, offering or receiving a kickback, bribe or rebate.
  • Secretly agreeing to any arrangement among parties that will result in higher charges to EmblemHealth.