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Health Care Fraud Prevention

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Fraud Costs Top $85 Billion a Year

Learn more about Health Care Fraud and The Special Investigation Unit at CareFirst and how to report fraud.







Reporting Fraud

Reporting suspect fraud is everyone's responsibility. Report suspected fraud to the CareFirst Special Investigations Unit by:

  • Calling 410-998-5480 or toll-free at 1-800-336-4522 (Phone calls can remain anonymous.);
  • Emailing SIU@CareFirst.com ;

Identifying Fraud

Health insurance fraud has many forms, but collectively it is costing upwards of $85 billion a year, according to the US General Accounting Office. The most common types of fraud include:

Providers

  • Billing for services that were offered for "free"
  • Billing for services that weren't provided
  • "Upcoding" - charging for a more complex or expensive service than was actually provided
  • Billing for a covered service when the service actually provided wasn't covered
  • Billing for services provided to their own family members

Members

  • Using a member ID card that doesn't belong to them
  • Not removing someone from their policy when they're no longer eligible (for example, former spouses or children who are no longer dependents)


  • Adding someone to their policy that isn't eligible (for example, grandchildren or overage dependents)

  • Doctor shopping - visiting several doctors to obtain multiple prescriptions (often for controlled substances)

As CareFirst members and providers, please help us fight fraud by letting us know when you encounter the following:

  • An Explanation of Benefits (EOB) showing services that you did not receive or showing providers or dates of service that are not correct
  • Someone using a member ID card that is not theirs
  • A member adding someone to his or her policy that is not eligible or not removing former spouses or children who are no longer dependent from a policy
  • Billing for services that were not provided
  • Billing for services that are more complex than the service that was performed

Preventing Fraud

You can help prevent fraud by keeping your member ID in a safe place. If your ID is stolen, report it immediately.