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Fraud Waste & Abuse

A current trend in healthcare fraud is robo-calls. We all get them, right? The ones who call you and mention your home warranty, or vehicle warranty. The fraudsters have gotten bolder and smarter and have started using the same technique to perpetuate healthcare fraud. Fraudster’s call and the caller id shows “1-800-MEDICARE” and they try and convince us to give them personal identification, DON’T FALL FOR IT!

Another trend in healthcare fraud is “unbundling” for services. This is a scheme in which a provider carves out individual codes and will bill for those codes individually, when the services should have been billed under one code. This increases the providers payment.

The Special Investigations Unit (SIU) uses proprietary software to help identify schemes in healthcare fraud. The software uses Artificial Intelligence to identify these schemes and trends. Using the software, the SIU recently identified a substantial overpayment to a provider with the support of the Claims Department. The company is working on a recoupment of the overpayment.


  • Protect your health insurance information. Treat it like a credit card. Don’t give it to others to use and be mindful when using it at the doctor’s office or pharmacy.
  • Beware of “free” services. If you’re asked to provide your health insurance information for a “free” service, the service is probably not free and could be fraudulently charged to your insurance company.
  • Check your Explanation of Benefits regularly. Make sure the dates, locations, and services billed match what you received. If there’s a concern, contact the KelseyCare Advantage Fraud Waste Abuse Hotline at 713-442-9595. You are part of the solution.
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