Report Insurance Fraud

Report Insurance Fraud

What is Insurance Fraud?

Insurance fraud is a crime. And far from being a victimless crime, insurance fraud victimizes every resident of New York State, costing consumers millions of dollars in the form of increased premiums and higher prices for goods and services. The exact cost of insurance fraud is difficult to estimate because much of it goes unreported.

Fraud, waste and abuse affect everyone. Fraudulent claims drive up the cost of insurance for every honest customer. Fraud amounts to between $125 billion and $175 billion annually, including everything from false Medicare claims to kickbacks for worthless treatments and other services. (Thomson Reuters, 2009). According to the National Health Care Anti-Fraud Association (NHCAA), financial losses due to health care fraud are in the tens of billions of dollars each year. (New York State Department of Financial Services (DFS), Annual Report: Investigating and Combating Health Insurance Fraud, March 15, 2014).

In addition to being costly, health insurance fraud occurs frequently and is pervasive. DFS reports that in 2013, it received 14,543 reports of suspected health care fraud during 2013 and that its health care fraud investigations resulted in 170 arrests. (DFS, Annual Report: Investigating and Combating Health Insurance Fraud, March 15, 2014).

Health care fraud is both a state and federal offense. Anyone who commits health care fraud may be subject to penalties including fines and imprisonment. (18 U.S.C. § 1347).

Definitions of Fraud, Waste and Abuse

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or state law, including 18 U.S.C. § 1347 and New York Insurance Law § 403.

Waste means an over-utilization of health care services or practices that result in unnecessary costs and does not rise to the level of Abuse.

Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the payor, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes member practices that result in unnecessary cost to the payor.

Examples of Potential Fraud, Waste or Abuse

Some examples of Fraud are:

• Providers knowingly billing for services not provided.
• Providers knowingly billing for the same service more than once (i.e., double billing).
• Providers knowingly billing for a more expensive service than what was provided (i.e.,upcoding).
• The misuse of a benefit card to receive medical or pharmacy services.
• Altering a prescription written by a doctor.
• Making false statements to receive medical or pharmacy services.
• Using stolen patient IDs to submit claims for services never provided.

Some examples of Abuse are:

• Misusing codes on the claim.
• Billing for a non-covered service.
• Billing as if each step of a procedure were a separate procedure (i.e., unbundling).
• Going to the Emergency Room for non-emergent medical services.

Some examples of Waste are:

• Providing services that are not medically necessary.
• Use of higher-priced services that have negligible or no health benefits over less-expensive alternatives.

CareConnect encourages members, providers, vendors, contractors, employees and the general public to report all cases of Fraud, Waste and Abuse. If you know of any employees, contractors, vendors, members or providers, including doctors, hospitals and pharmacies, who have committed actions of Fraud, Waste or Abuse, you can report them using the process described below. You may report them anonymously if you choose.

Our Special Investigations Unit (SIU)

The main function of this unit is to investigate allegations of fraudulent insurance activities. Members of the SIU attend industry meetings and trainings and interact with regulators to monitor current fraudulent schemes and red flags. The SIU works with the Centers for Medicare & Medicaid Services (CMS), Office of the Inspector General, New York State Department of Health and the DFS Insurance Frauds Bureau, as applicable. The SIU also works with the local district attorneys, New York Medicaid Fraud Control Unit, and United States Attorney General’s offices, as needed. In accordance with Article IV of the Insurance Law, the SIU helps ensure that the DFS Insurance Frauds Bureau is notified of all cases that CareConnect Insurance Company, Inc. determines, after investigation, are suspected fraudulent insurance activities.

How to Report Potential Fraud, Waste & Abuse

One of our key goals and ultimate responsibilities at CareConnect is to help create and foster an ethical business environment for our members, providers, vendors, contractors, employees, officers, Board members and the general public. The Special Investigations Unit of CareConnect Insurance Company, Inc. was established to enhance communication and to provide various mechanisms outlined below to report potential ethical issues or concerns, ask general questions about our policies and practices, and to report potential Fraud, Waste or Abuse. CareConnect is committed to identifying and stopping health care Fraud, Waste and Abuse. You can report Fraud, Waste, or Abuse through any of the following methods:

How to contact the Special Investigations Unit ("SIU") at CareConnect

• Call SIU Fraud Hotline toll free line at 855-228-0549
• Download the Suspect Fraud Report Form to provide the details of your suspected fraud complaint and send it to CareConnect by:
  • Email the SIU at siu@nslijcc.com
  • Fax the SIU at (516) 706-3829
  • Mail to:
    CareConnect Insurance Company, Inc.
    Attn: Special Investigations Unit 
    2200 Northern Blvd., Suite 104 
    East Hills, NY 11548

The EthicsPoint Helpline provides an alternative channel for you to communicate your concerns confidentially and anonymously if you so choose. Please know that when you use our EthicsPoint Helpline, you can report misconduct that you observe or gain clarity on whether or not something is a cause for concern. All questions, allegations, and suggestions will be reviewed and responded to in a timely and appropriate manner by the Compliance Department.

You may call our EthicsPoint Helpline to report your concerns 24 hours a day, 7 days a week at 1-800-894-3226. During off-hours, you can leave a voice mail message. Callers may remain anonymous. The information you provide will be forwarded within one business day to the CareConnect Compliance Department to address your concerns.

If you feel more comfortable sharing information online rather than over the phone, go to www.northwell.ethicspoint.com. This website is hosted by our parent company, Northwell Health System (formerly known as North Shore-LIJ Health System), and managed directly by EthicsPoint to ensure confidentiality and provide for anonymous reporting.

You may also report suspected fraud to the DFS in writing using the DFS Report Fraud Form, and sending it by facsimile or mail to:

New York State Department of Financial Services
Insurance Frauds Bureau
One State Street
New York, NY 10004
Fax: 212-709-3555