Fraud and Abuse
Constellation Health operates ethically and with the highest integrity requirement to ensure the best quality of service to our members and service providers, including the delegated entities. For this reason, we look to our members, providers, delegated entities and employees to learn how to identify and report erroneous behavior to avoid potential harm to our members.
What is Fraud?
Action or attempt to provide false information in order to obtain a benefit or profit without having the right to do it.
What is Abuse?
Abuse is an act the could, directly or indirectly result in: unnecessary costs to the Medicare Program, improper or dishonest payments, payments for services that do not meet with the basic care professionally recognized, or services that are medically unnecessary.
Some examples or Fraud & Abuse are:
- Billing for services not covered;
- Incorrect use of billing codes in claims (example: the way in which the service is coded in the claim does not comply with the national and/or local coding guides or is not billed as the service was provided);
- Drugs dispensed by the pharmacist are expired, adulterated or are illegal;
- Costs that are submitted incorrectly in the costs reports;
- Billing the same service more than once;
- Billing services or treatments that were not provided;
- Order excessive diagnostic tests that are not medically necessary; and/or
- Beneficiary share its membership plan card with another person and receives services on behalf of the beneficiary.
You can use the following mechanisms to report any conduct that you understand is suspicious and/or maybe interpreted as an act of fraud/abuse or non-compliance issues to:
Send a letter to:
PO BOX 364547
San Juan, PR 00936-4547
- To report potential fraud/abuse: email@example.com
- To report potential non-compliance: firstname.lastname@example.org
Call to our Hotline:
Remember, you can anonymously report any incident related to Fraud & Abuse. Constellation Health prohibits retaliation against anyone who, in good faith and better judgment, reports current or potential conduct that is interpreted as Fraud & Abuse.