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Fraud, Waste and Abuse

Healthcare fraud, waste and abuse affects everyone in the U.S. Let’s make sure you know what it is, how to spot it and how to help us prevent it. So, what is it exactly?

  • Fraud is when someone purposely lies to a health insurance company, Medicaid or Medicare to get money
  • Waste is when someone overuses health services carelessly
  • Abuse happens when best medical practices aren’t followed, leading to costs and treatments that aren’t needed

These are some of the ways our investigative team fights scams:

  • Looking carefully at claims and the information in them to spot red flags
  • Keeping a close eye on doctors’ billing patterns for unusual charges
  • Working with other healthcare companies to track suspicious activity
  • Partnering with law enforcement to investigate potential fraud
  • Training all our employees to spot unusual claims

How can you help?

  • Beware of freebies. If you are unsure if a service or extra benefit is for your plan, call the Member Services number on your member ID card.
  • Avoid identity theft. Don’t leave your member ID card out, and report it if it’s lost or stolen.
  • Review your explanation of benefits (EOB) if you get one in the mail. Your EOB is a snapshot of your doctor’s visit. When you get it, make sure the services listed match the services you actually got.

Reporting Fraud, Waste or Abuse

If you think a member or doctor is involved in fraud, waste or abuse, you should report it.

To report suspected fraud, waste or abuse to Clear Health Alliance, email us at SIU@simplyhealthcareplans.com or call the Member Services number on your card. Please give as many details as possible.

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, which is available online at https://apps.ahca.myflorida.com/mpi-complaintform/.

If you report suspected fraud and your report results in a fine, penalty or forfeiture of property from a doctor or other healthcare provider, you may be eligible for a reward through the Attorney General’s Fraud Rewards Program (toll-free 1-866-966-7226 or 850-414-3990). The reward may be up to twenty-five percent (25%) of the amount recovered or a maximum of $500,000 per case (Section 409.9203, Florida Statutes). You can talk to the Attorney General’s Office about keeping your identity confidential and protected.

Thank you for helping Clear Health Alliances’s efforts to find fraud, waste and abuse.