The Corporate and Financial Investigations Department (CFID) of AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey (collectively, AmeriHealth) continues to add value in our fight against health insurance fraud, waste, and abuse.
CFID detects, investigates, reports, and prevents potential fraud, waste, and abuse with the help of confidential information received from many stakeholders. This includes providers, members, employees, and the general public.
The National Health Care Anti-Fraud Association estimates that financial losses due to health care fraud are in the tens of billions of dollars each year. Health care fraud schemes continue to grow in complexity and seriousness and have real effects on health care costs and quality of care.
The information received assists our analysts, auditors, and investigators. Fraud in the health insurance sector can include:
- performing medically unnecessary surgeries or treatments to generate higher insurance payments.
- falsifying tests to justify unnecessary medical actions.
- accepting kickbacks for patient referrals.
- billing insurers for services that were not rendered or padding claims with charges for procedures that didn't occur.
- upcoding, which is the act of billing for more expensive services or procedures than were performed.
- unbundling, which is the act of billing each step of a procedure as one.
- misrepresenting non-covered treatments.
- waiving patient payments (copayments or deductibles) and charging these costs to the insurer or benefit plan.
- billing a patient for more than their copayment or deductible amount.
- prescription fraud.
What to do if you suspect health care fraud
All suspected fraud may be confidentially reported by using one of the following methods:
- Online through the Fraud & Abuse Tip Referral Form.
- By calling the confidential AmeriHealth anti-fraud and corporate compliance toll-free hotline at 1-866-282-2707 (TTY: 888-789-0429) from 8:30 a.m. to 4:30 p.m., Monday through Friday
- By writing a description of your complaint and enclosing copies of any supporting documentation. Mailed to AmeriHealth, Corporate & Financial Investigations Department, 1901 Market Street, 42nd Floor, Philadelphia, PA 19103.
Learn more
For additional information on how you can help fight fraud, waste, and abuse, visit the Anti-Fraud and Financial Investigations section of the AmeriHealth New Jersey and AmeriHealth Pennsylvania websites.