As your health insurance carrier, we encourage you to become an active participant in the fight against fraud in the healthcare industry by reporting suspicious activities related to medical and prescription drug coverage.

In accordance with state and federal laws, Health First Health Plans is required to establish and maintain a unit known as the Special Investigations Unit (SIU) to investigate suspicious activity. This internal unit is responsible for the detection, investigation, and reporting of potential fraud and abuse activity within our organization.

What is fraud?

Fraud is the intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person.

The most common type of health insurance fraud involves a false statement, misrepresentation, or deliberate omission that is critical to the determination of payable benefits. Fraud is a crime when an individual intentionally submits, or causes someone else to submit, false or misleading health information.

Some common healthcare fraudulent acts include, but are not limited to:

• Billing for services, procedures, and/or supplies that were not provided or rendered;
• Intentionally misrepresenting medical treatment for purposes of obtaining a higher reimbursement;
• Falsification of information to obtain benefits (i.e. enrollment forms, medical documentation);
• Forging or selling prescription drugs;
• Adding ineligible dependents to one's plan coverage;
• Using another's insurance information to obtain benefits;
• Failure to disclose information that may affect conditions of coverage;
• Providing false employer or group membership information to secure healthcare coverage;
• Obtaining a different prescription drug or dosage than what was prescribed by a physician.

How does healthcare fraud affect me?

The National Health Care Anti-fraud Association (NHCAA) estimates that conservatively three percent of all healthcare spending is lost to healthcare fraud estimated at $68 billion. Over time, this will result in:

• Higher premiums
• Higher costs to provide care
• Possible compromise in quality of care

By partnering together and increasing the awareness of healthcare fraud, waste and abuse, we maximize our efforts to detect and pursue the harmful effects of such activity.

How can you help?

• When in doubt, ask questions about the services you receive.
• In general, be careful about disclosing your insurance information. Protect your Health First Health Plans identification card.
• Compare your Explanation of Benefits (EOB) with your medical bills. If you are uncertain of the services billed, call the Customer Service department.
• Report suspected fraud to Health First Health Plans.

How can I report suspicious activities?

• Report fraud using our online form.
• Call the Health First Compliance and HIPAA Hotline: 1.888.400.4512 (TTY/TDD relay: 1.800.955.8771)
• We will treat any information that you provide with strict confidentiality. When reporting suspected health insurance fraud, you may remain anonymous.

When reporting suspicious activity, be sure to include all relevant information. Specify which person you believe is committing the fraud, date(s) of when the issue occurred, and provide details as to why you believe a fraudulent act may have occurred. Unless you choose to remain anonymous, please provide us your name and contact information so we may contact you with any additional questions during our investigation.