Pinnacle Health takes a strong stand against healthcare fraud as it detrimentally impacts us all. Collaborating with authorities, we actively work to prevent and reduce healthcare fraud to protect our members and uphold the integrity of the healthcare system. Join us in building a healthcare environment rooted in trust and integrity. Together, let's secure a healthier future.
What Is Healthcare Fraud?
Healthcare fraud is a federal crime under most criminal codes, consisting of intentional deceit for the purpose of illicit gains. Healthcare abuse is similar activity or behavior where knowing intent to obtain an unlawful gain cannot be established.
Some examples of healthcare fraud and abuse include:
- Phantom claims for services or supplies that were never provided.
- Using someone else’s medical insurance information to obtain services or supplies.
- Falsifying signatures or medical records to support misrepresented services or supplies.
- Unbundling services from a group to unlawfully increase medical payment.
- Misrepresenting the location where services or supplies are provided.Rendering medical care without a license.
- Duplicate claim submissions.
How to Protect Yourself from Healthcare Fraud
Although healthcare fraud is committed by a very small minority within the healthcare system, no one can assume it won't happen to them.
We encourage you to take these steps to avoid becoming a victim of healthcare fraud:
- After care, review your statement to verify accuracy.
- Ask your doctor to explain the reason for services.
- Report any discrepancies to your health insurance plan or payer.
- Beware of "free" medical services, as illicit entities use this lure to obtain information.
- Safeguard your insurance member ID card.
- Report instances where co-payments or deductibles are waived.
- Don’t give your insurance number to marketers or solicitors.
- Never sign a blank insurance form.
How to Report Healthcare Fraud
If you suspect, experience or witness healthcare fraud, you should report the information to your local Pinnacle Health Plans company by calling the number on the back of your member identification card. If you are not a member you can or call the report fraud hotline (866) 406-8319. If you are a federal employee or retiree, you can report potential healthcare fraud by calling (866) 406-8319.
The report fraud hotline cannot address medical benefit questions, individual payment disputes, expiration of benefits or other administrative concerns.
TELEPHONE FRAUD ALERT
We have received several complaints of an active fraud scheme in which a caller claims to be associated with “Pinnacle Health Plans” and uses call spoofing technology to make it appear as if the call is coming from the national “Call PHP” number (866) 406-8319). This number is only used to receive calls from members, not to make calls, and if you receive a call that appears to be from (866) 406-8319, the call is fraudulent or malicious and you should not answer it, or hang up immediately after receiving it if you do answer the call initially.
ROBOCALL SCAMS
If you get a recorded call from a caller whom you did not authorize to call you, the call is likely fraudulent or malicious and you should hang up immediately. Do not respond to prompts to “press 1 to speak to the operator or get your name taken off the list,” and do not provide any personal information. If you respond, you’ll probably get more calls. It is advisable to block the numbers of the robocalls you receive from calling your cell phone, although these callers may continue to call you from other numbers or use “spoofing” technology that makes the same calls appear to come from different numbers.
To report malicious or suspect robocalls and telemarketers, contact one or all of the following federal agencies:
The Federal Trade Commission at: https://ftc.gov/
The Federal Communications Commission at https://consumercomplaints.fcc.gov/hc
The Federal Bureau of Investigation, Internet Crime Complaint Center (IC3) at https://www.ic3.gov
