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 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 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 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

  • Call the Special Investigations Unit Fraud Hotline at 1-877-533-2400 
  • Email the Special Investigations Unit at 
  • Fax the Special Investigation Unit at (718) 393-6448

    Fidelis Care
    95-25 Queens Boulevard
    Rego Park, NY 11374
    Attn: Special Investigations Unit 
  • All Correspondence will be kept confidential

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

National Healthcare Anti-Fraud Association

Health and Human Services Office of the Inspector General

New York State Attorney General

New York State Department of Health

New York State Office of the Medicaid Inspector General

(Clicking these links will cause you to leave the Fidelis Care website)

Reporting Compliance Complaints and Fraud

Compliance Programs for Providers Accepting Medicaid

The New York State Office of the Medicaid Inspector General (OMIG) requires that, “Persons, providers, or affiliates are required to have a compliance program under New York State Social Services Law (SSL) § 363-d and 18 NYCRR Part 521 if they are a “required provider” as defined in 18 NYCRR § 521.2(a).  

Any provider who, in the aggregate, receives payments greater than $500,000 from Medicaid in any 12 month period is required to have a compliance program. The payments would include Medicaid FFS and payments received from a Medicaid managed care plan, such as Fidelis Care. 

For more information on whether or not you require to have a compliance program please visit the OMIG website Compliance section.