Anti-Fraud and Financial Investigations

Last year, the FBI estimated that between 3% and 10% of all health care spending in the U.S. went towards fraudulent claims. Fraud has real effects on everyone in the health care system. For members, fraud increases the costs of benefits and reduces the quality of care they receive. For employers, fraud increases the cost of providing benefits and the overall cost of doing business. Fraud can often result in unsafe medical procedures and false medical records which can lead to devastating effects.

Examples of fraud

Fraud can be committed by, and affect, stakeholders across every area of the health care system. Health care fraud is a serious crime that affects everyone’s health care and is a costly reality that we cannot afford to overlook.

Most common types of fraud

  • Billing for services not provided
  • Billing for more expensive services than were actually preformed, commonly known as upcoding
  • Performing medically unnecessary services solely for the purpose of reimbursement
  • Billing non-covered services (e.g., cosmetic) as other covered services
  • Prescription fraud and pharmaceutical diversion to include Medicare Part D
  • Providing false information during enrollment
  • Accepting bribes or kickbacks for patient referrals
  • Routinely waiving co-payments and/or deductibles
  • Medical identity theft

Protect yourself from fraud

  • Review your claims at amerihealthexpress.com by selecting “View Claims” to ensure you have received all services billed under your name.
  • Protect your health insurance card like you would a credit card.
  • Never provide health plan identification number to someone you don’t know.
  • Any free medical services being offered at community fairs or other events should never require you to provide your health plan identification number.

Anti-fraud efforts

AmeriHealth New Jersey’s Corporate and Financial Investigations Department (CFID) continues to add value to our fight against health insurance fraud, waste, and abuse (FWA). CFID detects and investigates potential areas of FWA with the help of confidential information received from many stakeholders, including providers, members, employees, and members of the general public. In 2013 alone, CFID recovered $2.99 million in fraudulent, abusive, or wasteful claims paid. In the last five years, over $8.73 million has been recovered by CFID in fraudulent, abusive, or wasteful claims.

Report fraud

CFID owes much of its success to the members, providers, and other stakeholders who have been instrumental in reporting fraudulent activities. If you suspect health care fraud against Independence and/or you, we urge you to report it. All reports are confidential. You are not required to provide your name, address, or other identifying information.
Three ways to report fraud

  1. Submit the Online Fraud & Abuse Tip Referral Form electronically.
  2. Call the confidential anti-fraud and corporate compliance hotline toll-free at 866-282-2707 (TTY/TDD 888-789-0429), 8:30 a.m. to 4:30 p.m., Monday through Friday.
  3. Mail your report. Write a description of your complaint, enclose copies of any supporting documentation, and mail it to:

AmeriHealth New Jersey
Corporate & Financial Investigations Department
1901 Market Street
Philadelphia, PA 19103

Our Corporate & Financial Investigations Department identifies, investigates, and seeks prosecution on internal and external fraud. We partner with state and federal law enforcement and regulatory agencies and other insurance companies in the fight against these crimes.

Health care fraud is a violation of state and/or federal law. Under federal law it is a felony offense (18 USC 1347), punishable by a fine of up to $250,000 and/or up to ten years’ imprisonment. If the violation results in serious bodily injury, up to a 20–year prison term is possible.

Anti-fraud case files

Our Corporate & Financial Investigations Department identifies, investigates, and seeks prosecution on internal and external fraud. We partner with state and federal law enforcement and regulatory agencies and other insurance companies in the fight against these crimes.

Health care fraud is a violation of state and/or federal law. Under federal law it is a felony offense (18 USC 1347), punishable by a fine of up to $250,000 and/or up to ten years’ imprisonment. If the violation results in serious bodily injury, up to a 20–year prison term is possible.

Sample Cases of Successful Fraud Prosecution

Case File #1: An owner/operator of a Durable Medical Supply company (DME Supplier) was sentenced to 66 months in federal prison. For submitting false and fraudulent claims for DME supplies that were never required nor ordered by the treating physicians. The owner/operator was charged with 48 counts of healthcare fraud, 6 counts of mail fraud, and 47 counts of paying illegal kickbacks for Medicare referrals among others. The owner/operator pled guilty to a total of 143 counts.

It was determined through CFID interviews, that medical equipment for subscribers was never requested and/or received, as well as never ordered and/or authorized by a physician. The DME supplier also billed for medical equipment for deceased and amputee members, as well as, physician and patient signature forgeries on various patient files documentation to include Medical Necessity letters.

Case File #2: A Pharmacist was convicted by a federal jury of conspiracy to distribute controlled substances and distribution of controlled substances and sentenced to 10 years in federal prison. The pharmacy was a haven for drug dealers and drug addicts who went there to fill false medical prescriptions for frequently abused prescription drugs containing controlled substances, such as Percocet, Lorcet, and Xanax, and the frequently abused syrups Tussionex and Phenergan with Codeine. The pharmacist filled the prescriptions knowing they were false. An involved physician separately plead guilty to issuing false scripts and was sentenced to 60 months in prison.

The pharmacist filled bundles of multiple false prescriptions for frequently abused prescription drugs in exchange for cash and other benefits. The pharmacist’s “customers” waited in line outside the pharmacy to have their fraudulent prescriptions filled. To avoid detection, the pharmacist set an artificial limit on the number of prescriptions he would fill per day from the physician so the prescriptions would not be consecutively recorded and reported to governmental authorities responsible for tracking prescriptions.