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Fraud & Abuse

Fraud, Waste, and Abuse Hurts Everyone.

It can even raise the cost of getting health care services. This is why we need help from our members and providers to find Fraud, Waste, or Abuse and stop it as soon as possible.

How YOU can help prevent Fraud, Waste and Abuse

As our Member, you play an important role in helping us find Fraud, Waste, or Abuse. If you feel that Fraud, Waste, or Abuse might be happening, report it as soon as you can. Here are some examples of possible fraud:

  • Someone pretends to be from Highmark Health Options and asks for your Social Security number, bank account or credit card numbers, money, etc.
  • A health care provider offers you cash or gifts to get free medical care
  • A pharmacy bills you for drugs you did not get, or the pharmacy did not give you the right number of pills ordered by your doctor
  • You find out someone else is using your health insurance card
  • You are billed for health care services or items you did not get
  • Your doctor is ordering a lot of tests or items that you do not feel you need

If you suspect Fraud, Waste, or Abuse, call us at 1-844-325-6256 so we may look into your concerns. You have the option to remain anonymous at all times. You do not have to give your name. Highmark Health Options has a team of people who look into all calls or mail regarding possible Fraud, Waste, or Abuse of health care services.

To report Medicaid Fraud, Waste, or Abuse you may contact Highmark Health Options by mail or phone at:

  • Highmark Health Options
  • Attention: Payment Integrity
  • Four Gateway Center, Suite 2100
  • 444 Liberty Avenue Pittsburgh, PA 15222

Or call the Fraud Hotline at: 1-844-325-6256

You may also report Fraud, Waste, or Abuse by calling the Department of Justice Provider Fraud Hotline. They can be reached by phone at 1-302-577-5000.

You have the option to remain anonymous at all times.

Keep Track of Your Health Services

When you get healthcare services, record the dates on a calendar and save the receipts and statements you get from your doctor to check for mistakes. You should keep track of these things:

  • Who provided your healthcare
  • What services you got during the visit and any tests or visits the doctor ordered
  • Where the healthcare visit took place
  • The date of your healthcare visit

Keeping track of your health services will not only help you to improve your health, it will also help you to know when there is a problem such as fraud.

Ways to protect yourself from Fraud, Waste, and Abuse

  • Do not give your health insurance card or card numbers to anyone other than your doctor, clinic, hospital or other healthcare provider
  • Call Highmark Health Options as soon as possible if your health insurance card is stolen
  • Check all bills, statements, or health care information you get. Make sure that the information is correct. If something does not look right, call us as soon as possible so we can look into it
  • Do not sign your name to any health care forms that are blank
  • Do not share your medical records with anyone other than your doctor, clinic, hospital or other health care provider

Additional educational resources can be found on the Centers for Medicare and Medicaid Services (CMS) website, or by watching this short Fraud, Waste, and Abuse video.

Fraud and Abuse Laws, Regulations, and Definitions

Provider Fraud, Waste and Abuse Training

Download and View the Provider Fraud, Waste and Abuse Training Document

This form is to tell us of suspected waste, fraud or abuse of services paid for by Highmark Health Options.

Please fill in as much of the information as you can below and click the submit button.

About the suspected member or provider:

Tell us about the activity that may be waste, fraud or abuse. Give details that tell us who, what, when, where, why and how. Some examples are:

Billing for services you did not receive

Someone using your identity to receive medical services.

How can we contact you?

Please provide your contact information so we can contact you is we have questions. Your identity will be protected to the extent allowed. Thank you for helping Highmark Health Option's efforts to find waste, fraud and abuse.