Health Care Fraud Prevention
Reporting Fraud
Reporting suspect fraud is everyone's responsibility. Report suspected fraud to the CareFirst Special Investigations Unit by:
- Calling 410-998-5480 or toll-free at 800-336-4522 (Phone calls can remain anonymous.)
- Completing the online form
Identifying Fraud
Health insurance fraud has many forms, but collectively it is costing upwards of $85 billion a year, according to the US General Accounting Office. The most common types of fraud include:
Members
- Using a member ID card that doesn't belong to them
- Not removing someone from their policy when they're no longer eligible (for example, former spouses or children who are no longer dependents)
- Adding someone to their policy that isn't eligible (for example, grandchildren or overage dependents)
- Doctor shopping - visiting several doctors to obtain multiple prescriptions (often for controlled substances)
Providers
- Billing for services that were offered for "free"
- Billing for services that weren't provided
- "Upcoding" - charging for a more complex or expensive service than was actually provided
- Billing for a covered service when the service actually provided wasn't covered
- Billing for services provided to their own family members
Please help us fight fraud by letting us know when you encounter the following:
- An Explanation of Benefits (EOB) showing services that you did not receive or showing providers or dates of service that are not correct
- Someone using a member ID card that is not theirs
- A member adding someone to his or her policy that is not eligible or not removing former spouses or children who are no longer dependent from a policy
- Billing for services that were not provided
- Billing for services that are more complex than the service that was performed
Preventing Fraud
You can help prevent fraud by keeping your member ID in a safe place. If your ID is stolen, report it immediately.