Fraud, Waste & Abuse
The Presbyterian Health Plan and Presbyterian Insurance Company's Special Investigative Unit (SIU) is responsible for the detection, investigation and reporting of potential and actual healthcare fraud, waste, and abuse. We are required to cooperate with regulatory and law enforcement agencies in reporting any activity that appears to be suspicious in nature. According to the law, any information we have concerning such matters must be turned over to the appropriate governmental agencies.
How to report Suspect Fraud, Waste, and Abuse to Presbyterian Health Plan and Presbyterian Insurance Company
You can contact the SIU 24 hours a day, seven days a week by leaving a telephone message on the confidential Fraud Hotline. We will treat any information you provide with strict confidentiality. When reporting suspect healthcare fraud, waste, or abuse, you may remain anonymous.FILE REPORT OF FRAUD, WASTE & ABUSE ONLINE
Presbyterian Health Plan Mailing address:
Presbyterian Health Plan Special Investigative Unit (SIU) P.O. Box 27489 Albuquerque, NM 87125-7489
When reporting suspect fraud, waste or abuse, please remember to include the names of all involved parties with knowledge of the alleged fraud, waste, or abuse. Specify who you believe is committing the fraud, waste, or abuse. Where did the fraud, waste, and abuse take place? Please give us the dates of service or issues in question and describe in detail why you believe a fraudulent, wasteful, or abusive act may have occurred. If possible, please include your name and telephone number so we may contact you if we have any questions during our investigation. The more information you are able to provide, the better able the SIU will be in successfully investigating the matter.
WHAT IS THE DEFINITION OF FRAUD, WASTE AND ABUSE?
Fraud is defined as an intentional deception or misrepresentation with the knowledge that the deception could result in some unauthorized benefit to a person or an entity.
Waste is defined as the thoughtless or careless expenditure, mismanagement, or abuse of resources.
Abuse is defined as incidents or practices that are inconsistent with accepted, sound business, fiscal or medical administrative practices.
While true fraud involves only a small percentage of individuals, the costs associated with it are high.
Suspicious activity exists when there is a reasonable belief that fraud, waste or abuse may have occurred.
Below are examples of what could occur and what to do if it does:
Examples of Provider Fraud:
Billing for services not rendered- billing for a service or visit the patient never received.
Altering medical records to pass an audit
Use of unlicensed staff to reduce costs
Drug diversion such as personal use or sale
Kickbacks and bribery such as paying a member for personal information to bill insurance for services not rendered
Examples of Member Fraud:
Falsification of information to obtain coverage
Forging prescriptions or selling prescription drugs
Using transportation benefit for non-medical related business such as going to Salon or Barber Shop
Adding an ineligible dependent to the plan
"Loaning" or using another's insurance card - allowing another person to use your insurance card
Examples of Broker and Agent Fraud:
Alteration of member application for insurance documents
Bribery and kickbacks
Falsification or misrepresentation of member and or group information to obtain reasonable rates. This act makes the applicant for coverage appear to be a better risk for policy acceptance
Failure to disclose information that may affect conditions of coverage
Sale of non-existent policies
Examples of Employer Group Fraud:
Providing false employer or group membership information to secure healthcare coverage
Falsification of information
Misrepresenting who is actually eligible for coverage by representing them as an employee of the group
Examples of Durable Medical Equipment (DME) Fraud:
Billing for equipment or supplies that were never provided to patients
You accepted an offer for “free” equipment or supplies but the insurance company was billed instead
Billing for different, more expensive equipment than what was provided to patient
Examples of Behavioral Health Fraud:
Billing for treatment that was never rendered
Being treated by a non-licensed provider
Examples of Non-Emergent Medical Transportation Fraud:
Using medical transportation to run personal errands; e.g., going to salon or barber
Examples of Part D Medicare Prescription Drug Benefit Fraud, Waste or Abuse:
An individual or organization pretends to represent Medicare and/or Social Security, and asks you for your Medicare or Social Security Number, bank account number, credit card number, money, etc.
Someone asks you to sell your Medicare prescription drug card
You feel a Medicare prescription drug plan has discriminated against you, including not letting you sign up for their plan because of your age, health, race, religion, or income
You were encouraged to disenroll from your plan
You were offered cash to sign up for a Medicare prescription drug plan
You were offered a gift worth more than $15 to sign up for a Medicare prescription drug plan
Your pharmacy did not give you all of your drugs
You were billed for drugs that you didn't receive
You believe that you have been charged more than once for your premium costs
Your Medicare prescription drug plan did not pay for your covered drugs
You received a different drug than your doctor ordered
New Mexico Attorney General Medicaid Fraud Control Unit (MFCU) The Medicaid Fraud & Elder Abuse Division (MFEAD) is the Medicaid fraud and elder abuse division of the New Mexico Attorney General’s Office, also known as the Medicaid Fraud Control Unit (MFCU). The MFCU investigates and prosecutes fraud committed in the Medicaid Program. PHP collaborates with this organization and supports their activities, reporting suspect cases as necessary, to investigate and prosecute bad actors within the program. To report Medicaid fraud, abuse, neglect, or exploitation, contact PHP. Otherwise, you may contact the MFCU at: New Mexico Office of the Attorney General Attn: Medicaid Fraud Control Division 201 Third St NW, Suite 300 Albuquerque, NM 87102 firstname.lastname@example.org 1-505-717-3500 or 1-800-525-6519
Medicare Prescription Drug Integrity Contractor (MEDIC) Toll-free 1-877-7Safe-Rx (1-877-772-3379) Fax: 410-819-8698
Office of the Inspector General (OIG) National Fraud Hotline Office of Inspector General US Dept. of Health and Human Services Attn: Hotline PO Box 23489 Washington DC 20026 Phone: 1-800-HHS-TIPS (1-800-447-8477) Fax: 1-800-223-8164 TTY: 1-800-377-4950 Email: HHSTips@oig.hhs.gov
The United States Office of Personnel Management (OPM) Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400 Washington, DC 20415-0001 Telephone: 202-418-3300 You may also call the Office of Inspector General Hotline Number at 1-877-499-7295
NOTE: Presbyterian Health Plan and Presbyterian Insurance Company are providing the above links because they may be of interest or useful to you. Presbyterian Health Plan and Presbyterian Insurance Company do not own, control, or influence these sites, and are not responsible for their content.