Fraud, Waste, and Abuse
Health care fraud is a crime that has a big impact on the health care system. It is possible for both members and health care providers to commit health care fraud.
The cost of fraud, waste, and abuse was more than $3 trillion in 2014, according to the National Health Care Anti-Fraud Association (NHCAA).
Anonymously report fraud, waste, or abuse
Call: Prestige Health Choice Fraud Tip Hotline at 1-866-833-9718.
Mail: Special Investigations Unit, 200 Stevens Drive, Philadelphia, PA 19113
Why should I care about fraud, waste, and abuse?
Fraud, waste, and abuse affect both health plan members and health care providers. They can:
- Keep you from getting medical services.
- Limit your health care benefits.
- Raise your taxes.
- Keep providers from being paid for services.
- Contribute to rising health care costs.
Health care fraud is a real crime with real consequences. It could lead to fines or even jail time.
What are fraud, waste, and abuse?
Fraud is a false statement from someone who knows that the statement is false.
- Example: Sam’s doctor provides a service to him that he knows won’t be covered. Sam’s doctor says that he provided a covered service instead.
Waste is when someone uses a service more than they need to.
- Example: Rachel asks 2 doctors to give her the same medicine. She now has more medicine than she needs.
Abuse may not be intentional. Abuse can lead to extra health care costs or losses to the health care system.
- Example: John’s doctor sends him to get an x-ray. John’s doctor knows that John does not really need one.
Remember: Report health care fraud to the Prestige Health Choice Fraud Tip Hotline at 1-866-833-9718.
Fraud rewards program
If you report suspected fraud and your report results in a fine, penalty, or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Attorney General's Fraud Rewards Program (toll free 1-866-966-7226 or 1-850-414-3990). The reward may be up to 25 percent of the amount recovered or a maximum of $500,000 per case (Florida statutes Chapter 409.9203). You can talk to the Attorney General's office about keeping your identity confidential and protected.
Additional information for members
To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll free at 1-888-419-3456 or complete a Medicaid Fraud and Abuse Complaint Form. You may also report suspected fraud or abuse by contacting the Florida Attorney General’s office at 1-866-966-7226.
Additional information for providers
Compliance with state and federal laws and regulations is a priority of Prestige. Providers contracted to provide health care services on behalf of Prestige beneficiaries who identify potential fraud, abuse, and overpayment are required to contact Prestige’s Hotline toll free at 1-866-833-9718 (Navex Global). Additionally, providers may report suspected fraud or abuse by contacting the Florida Attorney General’s office at 1-866-966-7226 or the Agency for Health Care Administration’s Consumer Hotline at 1-888-419-3456.