EmblemHealth Health Care Fraud

Health Care Fraud is a Crime

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.

Health Care Fraud Affects Everyone

Only a small percentage health care providers deliberately engage in acts of fraud. Why should you care about health care fraud? People who commit fraud 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 employers, fraud increases the cost of providing benefits to their employees. 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.

Examples of Health Care Provider Fraud

  • 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 copays or deductibles and over-billing the insurance carrier or benefit plan.

Examples of Health Care Member Fraud

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

What EmblemHealth is Doing to Stop Health Care Fraud

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.

How You Can Avoid and Prevent Health Care Fraud

  • 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.

How to Report Health Care Fraud

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

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

  • Report fraud by email.

Below are sites where you can learn more about fighting fraud.

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'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!

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


  • "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."


  • 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.


  • 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.