Fraud, Waste and Abuse
Health care fraud, waste and abuse affects everyone in the U.S. Let’s make sure you know what it is, how to spot it and how to help us prevent it. So, what is it exactly?
- Fraud is when someone purposely lies to a health insurance company, 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 costs and treatments that aren’t needed.
These are some of the ways our investigative team fights scams:
- Looking carefully at claims and the information in them to spot red flags
- Keeping a close eye on doctors’ billing patterns for unusual charges
- Working with other health care 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?
- Beware of freebies. If you are unsure if a service or extra benefit is for your plan, call the Customer Care Center 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 visit. When you get it, make sure the services listed match the services you actually got.
Reporting Fraud, Waste or Abuse
If you think a member or doctor is involved in fraud, waste or abuse, you should report it.
To report suspected fraud, waste or abuse to Healthy Blue, email us at firstname.lastname@example.org, or call the Customer Care Center number on your card. Please give as many details as possible.
To report suspected fraud and/or abuse in South Carolina Medicaid, call the Fraud Hotline toll-free at 1-888-364-3224 or email them at email@example.com.
Thank you for helping Healthy Blue’s efforts to find fraud, waste and abuse.