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Fidelis Care Special Investigations Unit

What is Healthcare Fraud?
Healthcare fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person, including any act that constitutes fraud under applicable federal or state law.
Provider Fraud and Abuse
Some examples of Provider Fraud and Abuse:
  • Billing for services or supplies that were not provided 
  • Altering or falsifying claim forms to obtain a higher reimbursement amount 
  • Deliberately applying for duplicate reimbursement in order to get paid twice 
  • Soliciting, offering, or receiving a kickback, bribe, or rebate for member referrals 
  • False representation with respect to the nature of the services rendered or charges for such services, identity of the person receiving or rendering the services, dates of the services, etc. 
  • Filing claims for services that are non-covered but billed as if they were covered services 
  • Claims involving collusion between a provider and a beneficiary, resulting in higher cost or charges to Fidelis Care
  • Billing for Brand name drug but dispensing a Generic
  • Billing for missed appointments
  • Balance billing Fidelis Care Members
Member Fraud
Some examples of Member Fraud:
  • Use of another person's Benefit card in obtaining medical care
  • Lending, renting or selling a Fidelis Care benefits card to another person 
  • Providing false information on your Fidelis Care application to make you eligible for coverage 
  • Altering or changing a prescription
  • Doctor Shopping
What Fidelis Care is Doing to Stop Fraud 
Fidelis Care has established its Special Investigation Unit to investigate allegations of Fraud by Providers, Members, Contractors, Employees or others. The Fidelis Care Special Investigation Unit is staffed by trained professionals who will vigorously look into each case. The Fidelis Special Investigation Unit has recently implemented a state of the art Fraud and Abuse detection system to further enhance its fraud fighting capabilities. Fidelis Care is committed to identifying and stopping healthcare fraud. 
Why You Should Report Healthcare Fraud 
According to The National Healthcare Fraud Association, "...estimates that of the nation's annual health care outlay, at least 3 percent - or $51 billion in calendar-year 2003 - is lost to outright fraud. Other estimates by government and law enforcement agencies place the loss as high as 10 percent of our annual expenditure - or $170 billion - each year." Like many other crimes Healthcare Fraud acts like a hidden tax increasing the costs for healthcare to everyone.

How to Contact the Special Investigation Unit at Fidelis Care

Fidelis Care
2501 Jackson Avenue
Long Island City, NY 11101
Attn: Special Investigations Unit 

All Correspondence will be kept confidential

How and where to report, return, and explain overpayments to Fidelis Care
If a provider or subcontractor identifies a claim overpayment by Fidelis Care, they are required under section 363-d of the Social Services Law to report, return, and explain the overpayment within sixty (60) days of identification:

  • Return the Overpayment: The SIU will review the overpayment and provide confirmation/instruction to the provider to return the overpayment via a check payment issued to Fidelis Care and mailed to: ATTN REFUND, SPECIAL INVESTIGATIONS UNIT, CENTENE CORPORATION, 7700 FORSYTH BLVD RM 519, CLAYTON, MO 63105-1807.

 Any reported self-disclosures an MMCO receives from a provider is reported on the MMCO’s Department of Health Cost Reports and monthly OMIG reports.

Learn more about Healthcare Fraud 

Visit these sites to learn more about healthcare fraud and how it affects you.