Fraud, Waste and Abuse

Healthcare fraud, waste and abuse affects everyone. Combating it begins with awareness.  Fraud is committed when a dishonest provider or consumer intentionally submits, or causes someone else to submit, false or misleading information for use in determining the amount of health care benefits. Waste is the over-utilization of services not caused by criminally negligent actions and the misuse of resources. Abuse is provider practices that are inconsistent with professional standards of care: medical necessity, or sound fiscal, business, or medical practices and provider or beneficiary practices that result in unnecessary costs to the healthcare program.

To learn more about fraud detection and prevention, click here.

What is provider fraud, waste and abuse?

• Billing for services not rendered
• Upcoding (billing for more expensive services or procedures than were actually provided or performed)
• Soliciting, offering or receiving kickbacks
• Improper of sloppy billing practices
• Failure to maintain adequate records
• Routine waiver of coinsurance and deductible.

What is member fraud, waste and abuse?

• Loaning or using another person’s insurance card
• Forging or selling prescription drugs
• Providing false information when applying for program benefits.

Unison is committed to combating fraud, waste and abuse. If you suspect health care fraud, waste and abuse, you may report via the following methods:

• Anonymous fraud, waste and abuse hotline: 1.877.766.3844
• Contact the Special Investigation Unit: 412.380.8011
• Access, print and mail a report form, click here
• File a report via the Internet, click here