Self-Service Login / Register | DiscoverHighmark
Powered by Google

Insurance Fraud

Adjust type sizesmallmediumlarge

Mission Statement:

The Special Investigation Unit’s (SIU) mission is to prevent, identify and investigate potential fraudulent and/or abusive behavior; to educate employees, members, and providers regarding fraudulent activities and to recover all monies possible and to refer cases for prosecution if necessary.

What is Fraud?

Fraud, as defined by Wall Street Words, is a deception carried out for the purpose of achieving personal gain while causing injury to another party. 

Fraud is considered a white-collar crime since it does not involve violence or bodily injury to another person.

Did you know?

  • The white-collar criminal has a much more stable family situation, is more likely to be married and less likely to be divorced, has more children and is more likely to be an active church member.
  • 30 percent of white-collar criminals are women.
  • The median loss caused by men is about $185,000; for women, it's $48,000.
  • Losses caused by managers are four times greater than those caused by lower-level employees; losses from fraud by executives are 16 times greater than those of their employees.

Healthcare Fraud:

Healthcare fraud, as defined by the National Healthcare Anti-Fraud Association (NHCAA), is:

The intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, or the entity or to some other party.

You may be surprised to learn that if you pay insurance premiums, you too are a victim of insurance fraud.

  • Insurance fraud is the second most costly white-collar crime, after tax evasion. (Insurance Fraud Prevention Authority)
  • More than half (55 percent) of U.S. consumers say poor service from an insurance company is more likely to cause a person to defraud that insurer. (Coalition Against Insurance Fraud)
  • Healthcare, workers compensation and auto insurance are believed to be the lines most vulnerable to insurance fraud.(Insurance Information Institute)
  • One in four Americans believe it’s ok to commit healthcare fraud. (Coalition Against Insurance Fraud)
  • One in five employed workers says they’ve been aware of fraud in their workplace. (Coalition Against Insurance Fraud)
  • Nearly one in three physicians says it’s necessary to game the healthcare system to provide high quality medical care. (Coalition Against Insurance Fraud)
  • The Justice Department launched 903 new health-care fraud prosecutions in the first eight months of FY 2011 more than all of FY 2010. (Coalition Against Insurance Fraud)
  • Insurance fraud is a major financier of America’s epidemic diversion of addictive prescription drugs such as OxyContin.(Coalition Against Insurance Fraud)

Did you know:

In Pennsylvania, insurance fraud is a felony crime, punishable by up to seven years in prison and up to $15,000 in fines, plus restitution, plus court costs. (Insurance Fraud Prevention Authority)

Don’t Become A Victim!

Beware of “free” offers.  It may be a scam to obtain your insurance information. 

The FBI has found that health care fraud costs the country an estimated $80 billion dollars a year.

We all pay in the form of higher health insurance premiums.  Our medical histories can be permanently altered when diseases or injuries we’ve never had are falsely entered on our records to justify the illegal charges.  (NHCAA)

Review all Explanation of Benefits (EOB) statements.  Don’t disregard them because they state “This is not a bill.”

Shred all documents with your personal information.  Health insurance information should be treated like credit card information.  In the wrong hands, it is a license to steal.

If you believe you’ve been the victim of insurance fraud, report it to Blue Cross of Northeastern Pennsylvania immediately. 

Fraud & Abuse Hotline: 1.800.438.2478