Fraud, Waste, and Abuse
The Presbyterian Health Plan and Presbyterian Insurance Company's Special Investigative Unit (SIU) is responsible for the detection, prevention, investigation and reporting of potential fraud, waste, 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 may contact the SIU 24 hours a day, seven days a week by calling the confidential fraud hotline. When reporting suspect fraud, waste, and abuse, please remember to include the names of all persons and/or parties involved. Let us know who you believe is committing the fraud, waste, or abuse. We also need to know the dates of service and the issues in question. Also, describe in detail why you believe fraud, waste, or abuse may have occurred. Information you provide Presbyterian is confidential to the extent allowed by law. You have the right to remain anonymous. However, 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 provide, the better able we are in investigating the suspect activity.
Hotline in Albuquerque:
Toll-free Hotline within the state of New Mexico: Email: PHPFraud@phs.orgPresbyterian Health Plan Mailing address: Presbyterian Health Plan Special Investigative Unit (SIU) P.O. Box 27489 Albuquerque, NM 87125-7489
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.
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.
Waste is defined as an act involving payment or the attempt to obtain payment for items or services where there was not intent to deceive or misrepresent, but where the outcome of poor or inefficient methods resulted in unnecessary costs to the plan.
Suspicious activity exists when there is a reasonable belief that fraud, waste, 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 Medicare Fraud:
Health and Human Services Office of the Inspection General National Fraud Hotline
Website: oig.hhs.gov/fraud/report-fraud/ Phone: 1-800-HHS-TIPS (
) Fax: 1-800-223-8164 TTY: Mailing Address: U.S. Department of Health and Human Services Office of Inspector GeneralATTN: OIG HOTLINE OPERATIONS P.O. Box 23489 Washington, DC 20026
To Report Medicare Part D Fraud:
Medicare Drug Integrity Contractor (MEDIC)
Phone: 1-877-7SAFERX (
)Have this information before you report to the MEDIC:
Your name and Medicare Number.
The provider’s name and any identifying information you may have.
The service or item you’re questioning and when it was supposedly given or delivered.
The payout amount approved and paid by Medicare.
The date on your Medicare Summary Notice or claim.