Fraud, Waste and Abuse

Health care fraud is contributing to the rising cost of health insurance.
Health care fraud reduces the amount of funds available to pay honest providers.
Health care fraud increases premiums to employers and members.
Ambetter from Arizona Complete Health will investigate allegations of fraud, waste and abuse – and reports of noncompliance on any level.
Ambetter from Arizona Complete Health's Special Investigations Unit is available as a resource to Health Net employees, members and providers, as well as to Ambetter from Arizona Complete Health's delegates – first tier, downstream, and related entities.
See below for examples of fraud and more.

Ambetter from Arizona Complete Health's Fraud hotline and Integrity hotline are available 24/7, and callers may choose to remain anonymous.

What to include in your report:

Unless you choose to remain anonymous, please provide your name, telephone number, address, and email address. If you are submitting your report anonymously, please take care to withhold personally identifiable information.
Explain the nature, scope and time frame of the activity in question.
Explain how you are aware of the alleged activity.
Specify if you know of any potential witnesses to the activity.
Provide any documents or other physical evidence in your possession.
For more information, please reference Centene Corporation Business Ethics and Conduct Policy (pdf).

The following links explain common fraud schemes that could impact members.

The following links address other important matters.

Some examples of consumer health care fraud:

Some examples of provider health care fraud:

billing for services not actually performed
falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary
upcoding – billing for a more costly service than the one actually performed

Some examples of non-compliance:

Five counties with high incidences of Fraud, Waste and Abuse*: