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Fraud, waste, and abuse

Health insurance fraud, waste, and abuse affects us all! Help us detect it!

Fraud, waste, and abuse affects you as a plan beneficiary, health plans, and service providers. Health resources are limited and it is important that they be used appropriately. Using resources inappropriately may result in a lower quality of medical services.

Therefore, it is important that any illegal or fraudulent act is reported immediately.

Triple-S Advantage is committed to reducing and controlling the incidence of fraud, waste, and abuse in the health insurance industry. For this purpose, our organization has a team of trained professionals with investigative experience who interact with local and federal agencies and other insurance companies to detect, prevent, investigate, and process cases of fraud.

What is fraud?

Fraud refers to any intentional and deliberate act to deprive another of property or money, through deception and other unfair means. It involves the intent to mislead or make false representations to obtain personal gain for oneself or others.

For example:

  • Filing claims for services and procedures that were not rendered; billing of supplies or medications that were not dispensed.
  • Lending the health insurance ID card to another person to obtain clinical services or medications.
  • Billing of a more complex service (more costly) than that which was rendered, to obtain a larger payment (upcoding).
  • Submitting false documents in order to obtain insurance reimbursements.
  • Billing of the same service more than once
  • Submitting a health plan enrollment application containing false or incomplete information.
  • Billing a full prescription when it was not dispensed in its entirety.

What is waste?

Is the use, consume, spend or expend thoughtlessly or carelessly.

For example:

  • A physician (unaware of the generic alternative) prescribing consistently a high priced medication instead of the less expensive drug available in the formulary.

What is abuse?

It is defined as the excessive and improper use of a product, service or benefit, or the use of something in a manner contrary to usual practices. This results in unnecessary costs for the health care system.

For example:

  • Overutilization of services or rendering of unnecessary clinical services.
  • Excessive ordering of diagnostic tests that are not medically justifiable.
  • Payment for services that do not comply with generally accepted standards of care.
  • That an employee uses corporate resources for personal use not related to work.

What can I do to prevent fraud and abuse?

  1. Read your claims carefully:  After care, review your statement to verify accuracy. Refer any suspicious claim to Triple-S Advantage.
  2. Protect the information on your ID card:  Never offer information about your health plan to solicitors over the telephone or to unknown persons. Don’t give your insurance number to marketers or solicitors. Safeguard your insurance card the same as you would your credit card.
  3. Get acquainted with the terms of your coverage and keep copies of medical tests to avoid repeating services.  If you visit several doctors, save a copy of labs or other test results and bring a list of the medications that you take. This way, you won’t have to repeat time-consuming and costly test.
  4. Check the information before signing any insurance application or health service claim to make sure it is correct. Never sign a blank enrollment form.
  5. Beware of “free” medical services, as illicit entities use this lure to obtain information.

How to report possible cases of fraud and abuse?

If you have any information or suspicion of a potential case of fraud or abuse to the health plan, or possible identity theft, you may contact our Compliance Department, Fraud and Abuse Unit at:

When you call or write it is important that you provide the following information:

  • Your name, contract number, telephone and address. Providing us your contact information is optional, you can file your report anonymous. However, if you provide us your information, you can assist us if we need to obtain any additional details about your referral.
  • Name of the person or entity that incurred in the potentially fraudulent action
  • Summary of the suspicious act (dates and what it is)
  • Manner in which you obtained the information or how you became aware of the suspicious act
  • Documents that you can provide to aid in the investigation

Your call will be handled in a strictly confidential manner, we will not retaliate, intimidate or discriminate in any way.  

It is everyone’s responsibility to make good use of the health plan.  We all pay for fraud!

Stop Medicare Fraud
How to Prevent Identity Theft
Prevent Fraud – Medical Supplies by Mail
Protect Future Generations
Protect your Identity!
Prevention and Detection of Financial Exploitation of Senior Citizens and Adults with Disabilities

Last update: 10/01/2016

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