Fraud, Waste and Abuse

Did You Know?

  • 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 Health Net will investigate allegations of fraud, waste and abuse – and reports of noncompliance on any level.
  • Ambetter from Health Net's Special Investigations Unit is available as a resource to Health Net employees, members and providers, as well as to Ambetter from Health Net's delegates – first tier, downstream, and related entities.
  • See below for examples of fraud and more.

How to Report

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

  • Ambetter from Health Net Fraud Hotline: 1-800-977-3565
  • Ambetter from Health Net Integrity Hotline: 1-888-866-1366
  • TTY: 711

What to include in your report:

  1. 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.
  2. Explain the nature, scope and time frame of the activity in question.
  3. Explain how you are aware of the alleged activity.
  4. Specify if you know of any potential witnesses to the activity.
  5. Provide any documents or other physical evidence in your possession.
  6. For more information, please reference Centene Corporation Business Ethics and Conduct Policy (pdf).

Fraud Awareness Tips

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

The following links address other important matters.

Examples of Fraud and Noncompliance

Some examples of consumer health care fraud:

  • filing claims for services or medications not received
  • forging or altering bills or receipts
  • using someone else's coverage or insurance card

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:

  • theft or unauthorized removal of company/business documents from the premises
  • falsifying or tampering with company documents or records
  • violations of Ambetter from Health Net's Code of Conduct
  • insubordination, dishonesty, gross carelessness/negligence of duties

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

  • Broward County, Florida
  • Harris County, Texas
  • Kings County, New York
  • Los Angeles County, California
  • Miami-Dade County, Florida.
*As of July 1, 2011, Centers for Medicare & Medicaid Services identified these five counties as most at risk for high incidences of fraud, waste and abuse.