Report fraud, waste, or abuse

Health care fraud is a crime that has a big impact on the health care system. It is possible for both members and health care providers to commit health care fraud.

The cost of fraud, waste, and abuse was more than $3 trillion in 2014, according to the National Health Care Anti-Fraud Association (NHCAA). You can anonymously report fraud to Keystone First with the secure contact form.

You can also contact:

• MA Provider Compliance Hotline at 1-866-379-8477.
• Pennsylvania Department of Human Services’ Bureau of Program Integrity.

Why should I care about fraud, waste, and abuse?

Fraud, waste, and abuse affect both health plan members and health care providers. They can:

• Keep you from getting medical services.
• Limit your health care benefits.
• Raise your taxes.
• Keep providers from being paid for services.
• Contribute to rising health care costs.

In addition, health care fraud is a real crime with real consequences. It could lead to fines or even jail time.

What are fraud, waste, and abuse?

Fraud is a false statement from someone who knows that the statement is false.

• Example: Sam’s doctor provides a service to him that he knows won’t be covered. Sam’s doctor says that he provided a covered service instead.

Waste is when someone uses a service more than they need to.

• Example: Rachel asks 2 different doctors to give her the same medicine. She now has more medicine than she needs.

Abuse may not be intentional. Abuse can lead to extra health care costs or losses to the health care system.

• Example: Jonathan’s doctor sends him to get an X-ray when he does not really need one.

How to spot fraud, waste, and abuse

You can help Keystone First uncover fraud, waste, and abuse. You should keep track of the following things:

• Who provided your health care.
• What services you received during the visit and any additional tests or visits the doctor ordered.
• When you got a health care service.
• Where the service was provided.

Contact Keystone First or the Pennsylvania Department of Human Services if you suspect fraud, waste or abuse. Please remember, do not:

• Give your ID card or number to anyone other than your doctor, clinic, hospital, or other health care provider.
• Ask your doctor or any other health care provider for medical services or supplies that you don’t need.
• Sign your name to a blank form.
• Share your medical records with anyone other than your doctor, clinic, hospital or other health care provider.

Keystone First has a team that works hard to identify and prevent fraud, waste, and abuse. But we still need members to report suspected fraud, waste and abuse.

Remember: Report health care fraud to the Keystone First Fraud Tip Hotline at 1-866-833-9718.