Waste, Abuse and Fraud

Health care waste, fraud and abuse cost Americans billions of dollars every year. We all pay in reduced benefits, higher taxes, increased premiums, and more expensive doctor visits and prescriptions. Please take time to view these pages and report any acts of waste, abuse or fraud.

To report suspected fraud via our Anonymous Fraud Hotline, please call: 1-800-8ETHICS (1-800-838-4427)

All calls are private. We also have a compliance hotline, 1-800-8ETHICS (1-800-838-4427). Or you can call the Texas Department Of Insurance at 1-800-252-3439 or send a letter to:

Fraud unit
P.O Box 149336
Mail Code 109-3A
Austin TX 78714-9336

Definitions of Waste, Abuse and Fraud

Waste is generally defined as activities involving payment or the attempt to obtain reimbursement for items or services where there was no intent to deceive or misrepresent but the outcome of poor or inefficient billing or treatment methods causes unnecessary costs to the government program.

Abuse is generally defined as activities that unjustly enrich a person through the receipt of benefit payments but where the intent to deceive is not present; or is an attempt by an individual to obtain a benefit payment he or she does not deserve.

Fraud is an intentional representation that an individual knows to be false or does not believe to be true and makes anyway, knowing that the representation could result in some unauthorized benefit to him/herself or some other person.

How to Identify Provider Fraud

Fraud is a deliberate deception or misrepresentation that someone makes in order to receive benefits he or she does not deserve.

The large majority of doctors and other health care providers are honest and hardworkidsng people whose only concern is your health. Unfortunately, a few providers engage in fraudulent billing.

Examples of fraudulent billing practices include:

  • Billing for services or items that were never provided
  • Billing separate claims for services that should be billed together as a single item
  • Billing for services or equipment that are more expensive than what was supplied
  • Continuing to bill for home medical equipment after it has been returned
  • Scheduling unnecessary office visits or ordering unnecessary x-ray, laboratory or other services
  • Taking payment from another provider in exchange for referring a patient
  • Allowing an unlicensed person to perform treatment and billing as if a qualified individual had performed the service.

How to Identify Recipient Fraud

Fraud is a deliberate deception or misrepresentation that someone makes in order to receive benefits he or she does not deserve.

Most people are honest and hardworking. A few individuals try to game the system to receive money or benefits they don't deserve. They are making a mistake-it is a crime to commit insurance fraud, and people can lose their benefits for it, and be prosecuted.

Examples of fraudulent recipient activities include:

  • Loaning their health care identification card or other insurance card to another person
  • Using someone else's health care identification card
  • Forging or altering a prescription
  • Doctor shopping in order to obtain multiple prescriptions Intentionally receiving unneeded services or supplies
  • Accepting cash or other bribes for receiving services
  • Re-selling items provided by government health programs
  • Deliberately giving incorrect information to receive benefits

How You Can Help Detect and Prevent Fraud

Fraud takes many shapes. Recipients can help uncover and stop wrongful billing practices. One way to help stop waste, abuse and fraud is to keep a record of your medical treatment.

Write down:

  • The date you received medical care
  • Where the service took place
  • What services were provided to you
  • The names of who provided the services
  • What tests or additional services were ordered by the providers

You should be suspicious if the provider tells you that:

  • The test is free; he only needs your insurance number for his records
  • They know how to get your insurance to pay for it
  • The more tests they provide the cheaper they are
  • The equipment or service is free; it won't cost you anything
  • Advertise "free" consultations in exchange for your insurance information
  • Use telemarketing and door-to-door selling as marketing tools

To help prevent fraud, report your suspicions. When you receive an Explanation of Benefits, review it for errors. The payment notices show what your insurance was billed, what was paid and what you owe. Make sure you were not billed for health care services or medical supplies and equipment you did not receive.

To report fraud, waste or abuse click here.

To report compliance concerns click here.

Click here to read the Standards of Conduct.

Visit your member portal to look up benefits, check your claim status, and much more.

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Allegian Health Plans, 4801 NW Loop 410 Ste. 300, San Antonio, TX 78229

Main Number (855) 381-3442
TRS-ActiveCare Members (855) 463-7264