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Fraud and Abuse

The Presbyterian Health Plan and Presbyterian Insurance Company's Special Investigative Unit (SIU) is responsible for the detection, investigation and reporting of potential fraud and abuse activity. 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 that we have concerning such matters must be turned over to the appropriate governmental agencies.


How to report Suspicious Activity to Presbyterian Health Plan and Presbyterian Insurance Company

You can contact the SIU 24 hours a day by leaving a telephone message on the confidential fraud hotline. We will treat any information that you provide with strict confidentiality. When reporting suspected health insurance fraud, you may remain anonymous.

Hotline in Albuquerque: 505-923-5959
Toll-free Hotline within the state of New Mexico: 1-800-239-3147
Email: PHPFrau@phs.org
File Report of Fraud Online

Presbyterian Health Plan Mailing address:
Presbyterian Health Plan
Special Investigative Unit (SIU)
P.O. Box 27489
Albuquerque, NM 87125-7489

When reporting suspected fraud, please remember to include the names of all applicable parties involved. Specify which person you believe is committing the fraud, identify the dates of service or issues in question and describe in detail why you believe a fraudulent 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.


What is the definition of Fraud 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.

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 or abuse may have occurred.

Examples of Provider Fraud:

  • Billing for services not rendered
  • Altering medical records
  • Use of unlicensed staff
  • Drug diversion
  • Kickbacks and bribery

Examples of Member Fraud:

  • Falsification of information
  • Forging or selling prescription drugs
  • Using transportation benefit for non-medical related business
  • Adding an ineligible dependent to the plan
  • "Loaning" or using another's insurance card

Examples of Broker and Agent Fraud:

  • Alteration of 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 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

Anti-Fraud Contacts

To Report Public Assistance Fraud:

Call: 800-228-4802
Email: HSDOIGFraud@state.nm.us

To Report Medicaid Provider Fraud:

Call: 505-827-3146
Email: HSD-NMMedicaidFraud@state.nm.us

New Mexico Attorney General Medicaid Fraud Control Unit
1-800-525-6519

Centers for Medicare and Medicaid Services (CMS)

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

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Last Updated: 09/30/2015