Fraud, Waste, and Abuse

Fraud, waste, and abuse hurts everyone

It can even raise the cost of getting health care services. This is why we need help from our members and providers to find fraud, waste, and abuse and stop it as soon as possible. As our member, you play an important role in helping us find fraud, waste, and abuse. If you feel that it might be happening, report it as soon as you can. Here are some examples of possible fraud:

• A health care provider offers you cash or gifts to get free medical care.
• A pharmacy bills you for drugs you did not get, or the pharmacy did not give you the right number of pills ordered by your doctor.
• Someone pretends to be from Highmark Health Options and asks for your Social Security number, bank account or credit card numbers, money, etc.
• You are billed for health care services or items you did not get.
• Your doctor orders a lot of tests or items that you do not feel you need.
• You find out someone else is using your health insurance card.

Do you suspect fraud, waste, and abuse?

We have a team of people who look into all calls or mail regarding possible fraud, waste, and abuse of health care services. You have the option to remain anonymous at all times. You do not have to share your name when making a report. Tell us of suspected fraud, waste, and abuse of services paid for by Highmark Health Options.

To report Medicaid fraud, waste, and abuse, contact Highmark Health Options:

Keep track of your health services

When you get health care services, record the dates on a calendar and save the receipts and statements you get from your doctor to check for mistakes. You should keep track of these things:

• The date of your health care visit.
• What services you got during the visit and any tests or visits the doctor ordered.
• Where the health care visit took place.
• Who provided your health care.

Keeping track of your health services will not only help you to improve your health, but it will also help you to know when there is a problem such as fraud. Ways to protect yourself from fraud, waste, and abuse:

• Call Highmark Health Options as soon as possible if your health insurance card is stolen. 
• Check all bills, statements, or health care information you get. Make sure that the information is correct. If something does not look right, call us as soon as possible so we can look into it. 
• Do not give your health insurance card or card numbers to anyone other than your doctor, clinic, hospital or other health care provider. 
• Do not share your medical records with anyone other than your doctor, clinic, hospital or other health care provider. 
• Do not sign your name to any health care forms that are blank.

Additional resources for providers

• Centers for Medicare and Medicaid Services (CMS)
• Fraud and Abuse Laws, Regulations, and Definitions
• Provider Self-Audits for Overpayments
• 2024 Audit Plan – Supplemental Guide
• 2024 Anti-Fraud Plan
• 2024 Provider Fraud, Waste, and Abuse Training