Fraud is when a person or provider knowingly makes or permits another person to make a false statement in order to get services, items or a payment that the person or provider does not have a right to receive.
Abuse is when a person or provider acts in a way that results in unnecessary healthcare costs. Abuse could include a provider rendering a medically unnecessary service or billing in a way that makes a service more costly than necessary.
Here are some examples of fraud and abuse:
- A member submits false or misleading information on a membership application form
- A member makes a false request for reimbursement
- A member fails to notify Tufts Health Direct of changes (such as residency) that affect a member's eligibility
- A member lends his or her Tufts Health Direct member ID card to another person so he or she can get health care or pharmacy services
- A member uses pharmacy benefits to obtain medications that are not medically necessary
- A member’s Explanation of Benefit (EOB) statement shows claims not belonging to them
- A member’s pharmacy claims show medication fills not belonging to the member
- A provider bills for a service they did not provide, or a different service than the one they provided
- A provider agrees to waive copays or deductible charges in exchange for agreeing to services
- A provider or broker assists a member to apply for insurance in exchange for agreeing to services
To report potential health care fraud and abuse or if you have questions, please call us at 888-257-1985, Monday through Friday, 8 a.m. to 5 p.m., or email [email protected]. We don’t need your name or member information. You can also call our confidential hotline anytime at 877-824-7123 or send an anonymous letter to us at:
Point 32 Health
Attn: Special Investigative Unit (SIU) B1
1 Wellness Way
Canton, MA 02021-1166