How PEHP is Fighting Fraud

Health care fraud and abuse increases costs and may result in lower benefits and higher premiums. Please be informed so you'll know how you can help.

What is Health Care Fraud and Abuse?

Health Care Fraud is an intentional deception or misrepresentation performed by an individual or entity, knowing the misrepresentation could result in some unauthorized benefit to the individual, or entity or some other party.

Health care abuse is any activity that misuses the health care system but does not meet the statutory definition of fraud. Examples may include over-utilization of services, billing for one service when a lesser service was performed and billing for procedures individually when they should be billed as a group.

PEHP has developed a special Investigative Unit (SIU) to combat the growing trend in health care fraud and to assist in stemming rising health care premiums and possible loss of benefits.

Keys to Fighting Fraud

1. Identify
   PEHP trains its employees to identify fraud and abuse and to contact the SIU when fraud is suspected.
2. Investigate
   The SIU staff performs desk top audits and on-site audits at the provider’s office if necessary. These audits verify correct coding of procedures billed, sufficient supporting documentation of services, and medical necessity for the services billed. When the SIU identifies overpayments PEHP pursues reimbursement of the monies paid in error.
3. Prevention
   PEHP’s claim processing system as well as the Medical Review Department identify illogical and inconsistent claims data, so the information can be reviewed before payment is made. PEHP uses state of the art software to detect possible fraud and to identify those providers and members who may be involved.
4. Report
   Call PEHP’s 24 hour confidential toll free hotline: 888-475-8376. You may also submit a confidential, anonymous report electronically by clicking here.

How Health Care Fraud Impacts You

It can lead to increased health care premiums and decreased benefits. and possible falsification of medical records, including treatment history.

How You Can Help

Review your Explanation of Benefits (EOBs) and quarterly statements received from PEHP for charges that seem incorrect or charges for services you don’t recall receiving. Report your concerns to PEHP’s 24 hour confidential toll free hotline 888-475-8376. You may also submit a confidential, anonymous report electronically by clicking here.