Fraud, Waste, And Abuse

Healthcare fraud, waste, and abuse affects everyone. What is it?

  • Fraud is when someone lies to us, Medicaid, or Medicare to get money.
  • Waste is when someone overuses health services carelessly.
  • Abuse happens when best medical practices aren’t followed, leading to expenses and treatments that aren’t needed.


How It Impacts You


Healthcare fraud, waste, and abuse can make things harder for you because it:

  • Increases your health risk if providers don’t have accurate medical history or suggest services or procedures you don’t really need.
  • Prevents you from getting security clearances if your health records have been compromised.


Identity Theft


Healthcare fraud, waste and abuse can also make you vulnerable to identity theft. Like credit card identify theft, medical identity theft costs time and money and compromises your safety.


If someone steals your information to get services, they could use up all your benefits, leaving you without them when you actually need care. A compromised health record also puts you at risk for getting treatments you don’t need and can keep you from getting life insurance in the future.


What Are We Doing?


These are some of the ways our investigative team fights scams:

  • Looking carefully at claims and the information in them to spot errors
  • Keeping a close eye on doctors’ billing patterns for weird or suspicious charges
  • Working with other healthcare companies to track suspicious activity
  • Partnering with law enforcement to investigate potential fraud
  • Training all our employees to spot unusual claims


How Can You Help?


Watch out for freebies. If you are unsure if a service or extra benefit is for your plan, call the Member Services number on your member ID card.
Avoid identity theft. Don’t leave your member ID card out and report it if it’s lost or stolen.
Review your explanation of benefits (EOB) if you get one in the mail. Your EOB is a snapshot of your doctor’s visit. When you receive it, make sure the services listed on it match the services you actually received.


If you think you’ve spotted an incident of healthcare fraud, waste, or abuse, you can:

Please give as many details as possible about the situation. Tell us who, what, where, when, why, and how, including:

  • The full name of the suspected member or doctor.
  • The doctor’s or member’s address.
  • The doctor’s or member’s telephone number.
  • Any information about the member or doctor that makes you believe they may be engaged in fraudulent activity.
  • The date(s) and time(s) related to the incident.

You can also report anonymously. Call the member services number on your card. If you feel comfortable, it is helpful for us if you also give us your contact information so we can reach you if we have questions. Please provide your:

  • Full name.
  • Address.
  • Telephone number.
  • Email address.

Your identity will be protected to the extent allowed. Thank you for helping Healthy Blue’s efforts to find fraud, waste, and abuse.

Y0114_21_3000909_I_C 09/02/2021