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CFID fights fraud, waste, and abuse

May 1, 2014

Last year the FBI estimated that between 3 percent and 10 percent of all health care spending in the U.S. went towards fraudulent claims. Fraud has real effects on health care costs and quality of care. The AmeriHealth 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, AmeriHealth associates, and the general public.

Information received assists our analysts, auditors, and investigators in determining whether potential FWA has occurred. Some of the most common potential FWA schemes reported to CFID over the past year include:

  • billing for services not rendered
  • health care identity fraud
  • prescription fraud
  • improper use of procedure codes
  • claim lines billed with units exceeding the medically unlikely edits (MUE) limits, according to the Centers for Medicare & Medicaid Services

If you suspect health care fraud against you and/or AmeriHealth, we urge you to report it. All reports are confidential; you are not required to provide your name, address, or other identifying information.

Submitting a report

You have three options for submitting a report:

  1. Submit the Online Fraud & Abuse Tip Referral Form electronically.
  2. Call the confidential anti-fraud and corporate compliance toll-free hotline at 1-866-282-2707 (TTY# 1-888-789-0429).
  3. Mail your report. Write a description of your complaint, enclose copies of any supporting documentation, and mail it to:
    AmeriHealth
    Corporate & Financial Investigations Department
    1901 Market Street, 15th Floor
    Philadelphia, PA 19103

As a result of CFID?s efforts last year, $65.8 million was recovered in FWA-related claims and 38 fraud cases were referred to law enforcement or regulatory agencies. In addition, savings consisting of many times the recovered amount were recognized through the detection, prevention, and shutting down of improper payments and schemes. Many of these recoveries and referrals started with information someone provided to CFID.

Please join us in the fight against health care fraud.


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