Health Care Fraud

Billions of dollars are lost to health care fraud each year. The goal of the Special Investigations Unit (SIU) is to detect, deter, and ultimately, end fraud. Health care fraud can affect everyone…including you. Only a small percentage of health care providers and consumers engage in health care fraud. However, even a small amount of health care fraud can raise the cost of health care benefits for everyone.

What is Health Care Fraud

Fraud is stealing and it is a crime.  It’s committed when a dishonest provider or consumer intentionally submits, or causes someone else to submit false or misleading information in order to obtain benefits they may not be entitled to. Some examples of provider health care fraud are:

  • Billing for services not actually performed
  • Falsifying a patients diagnosis to justify test, surgeries or other procedures that aren’t medically necessary
  • Misrepresenting procedures performed to obtain payment for non-covered services, such as cosmetic surgery
  • Upcoding - billing for a more costly service than the one actually performed
  • Unbundling - billing each state of a procedure as if it were a separate procedure
  • Accepting kickbacks for patient referrals
  • Waiving patient co-pays or deductibles and over-billing the insurance carrier or benefit plan
  • Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.

Some examples of consumer health care fraud are:

  • Filing claims for services or medications not received
  • Forging or altering bills or receipts
  • Using someone else’s coverage or insurance card
  • Leaving your spouse on your health insurance contract after your divorce date
  • Leaving other dependents (children) on your health insurance contract when they are no longer eligible (age, marriage)

Our Special Investigations Unit

Six full time employees, whose main function is to investigate allegations of fraud and abusive billing practices, staff the Special Investigations Unit.  The staff includes an accredited Health Care Fraud Investigator, Registered Nurses with coding backgrounds, an Accountant as well as an Information Specialist.

The unit is a member of the National Health Care Anti-Fraud Association which provides current information on legislation and continuing education for all staff members.

Our Relationship with Law Enforcement Agencies

The Special Investigations Unit has an ongoing relationship with the New York State Insurance Department Frauds Bureau.  As required by Article IV of the Insurance Law, the Insurance Department is notified of all instances of suspected fraud. The Unit works closely with the Frauds Bureau on these investigations.

The unit also works directly with the local district attorneys, Medicaid Fraud Control Units, United States Attorney General’s offices as well as each entity’s investigative arms. The department Director is part of the U.S. Attorney’s Office Task Force on Health Care Fraud. The Unit also has ongoing relationships with regulatory and enforcement agencies such as the Department of HHS, FBI, Inspector General, U.S. Post Office, and the New York Departments of Education and Health

View our policy on Fraud Laws and Whistleblower Rights and Protections (pdf)

How to Report Potential Fraud & Abuse

Call our Fraud Hotline 1-800-665-1182. Callers may remain anonymous. In addition, you can report possible fraud and/or abuse situations by using the Special Investigations Unit Form. Please note that filling in all of the information on the form is optional, and will remain confidential if entered. Personal information such as name, home address, telephone number and/or Email address will be used only if we need to contact you for more information. Once the information has been entered, mail the form to:

c/o Independent Health, Inc.
511 Farber Lakes Drive
Williamsville, NY 14221
Fraud and Abuse Reporting form (pdf)