We receive thousands of tips a year, conduct hundreds of investigations, and refer dozens of cases to local and federal authorities for prosecution.
Our Special Investigative Unit (SIU) is managed by former federal and state law enforcement investigators and is staffed with registered nurses, data analysts and experienced fraud investigators certified by the American Association of Professional Coders.
Identify: We train our employees to identify fraud and abuse and to contact the SIU.
Investigate: We conduct in-house and on-site audits to verify coding, documentation and medical necessity for the services billed. When the SIU identifies overpayments, it pursues reimbursement of funds paid.
Cooperate: We work with other insurers, plus local, state and federal agencies to identify and prevent fraud, and to recover funds fraudulently obtained.
Prevent: We use state-of-the-art software to detect inconsistencies, fraud patterns and to identify those providers and members who may be involved, even before payment is made.
We protect members in the case of medical ID theft.
When a member contacts our Customer Service to report a stolen or lost health plan card:
- A Customer Service representative enters the information into our computer system.
- The member is issued a new card.
- The Special Investigation Unit automatically receives notification of the lost/stolen card.
If the member has a pharmacy benefit, Pharmacy Services automatically receives notification of the lost/stolen card.
This coordinated, proactive approach helps us spot fraud resulting from the card theft, to protect members’ medical records and benefits.