Fraud and Abuse Investigations

Fraud and abuse, while engaged in by a only a small percentage of healthcare providers, is a major challenge for health plans. Reasonable efforts to detect and eliminate fraudulent and abusive practices are important to contain healthcare costs.

Incidents of fraud and abuse may include:

• Billing for services not provided
• Incorrectly coding for more complex services than actually were performed (upcoding)
• Falsifying medical records to support fraudulent billing
• Providing and billing for services, supplies or equipment not medically appropriate

Detection of Fraudulent Practices

HMSA's Special Investigations Unit conducts fraud and abuse investigations when warranted as a result of potential fraud being identified through various means, including the following:

• Data analysis identifying provider billing patterns outside the norm for the specialty group
• Complaints from members
• Complaints from office staff
• Reports to the Fraud Hotline
• Information received from government agencies or other insurers

HMSA may request medical records to verify that services were provided and appropriately billed. If HMSA finds that services were not appropriately billed, the provider will be notified of HMSA's findings and HMSA will seek to recover any overpayments. If the provider does not agree with the HMSA's findings, he or she can file an appeal (see Appealing Processed Claims).

If during an investigation, criminal activity is suspected, the case will be referred to law enforcement for a possible criminal investigation

HMSA's Fraud Hotline number is 808-948-5166 on Oahu and 1-888-398-6445 from the Neighbor Islands and the Mainland.

For additional information on HMSA's efforts to minimize fraud and abuse, refer to Fraud is Everyone’s Business.

Revision History