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Like you, we’re committed to maintaining the highest ethical standards and protecting the integrity of the care our members receive. A critical part of this commitment is our shared responsibility to prevent, detect and report healthcare fraud, waste and abuse (FWA). 

Geisinger Health Plan has zero tolerance for any form of FWA. Because we must adhere to all regulatory program integrity standards, we’re equipping you with the knowledge needed to prevent potential FWA in your daily practice.

Examples of actions that may constitute fraud include: 

  • Medical necessity: Providing or misrepresenting information that is not a true reflection of member’s condition to obtain authorization of services. This includes submitting letters of medical necessity with inaccurate information.
  • Billing for services not rendered: Submitting claims for treatments or procedures that never occurred.
  • Upcoding: Billing for a more expensive service or procedure than the one performed to receive a higher reimbursement rate.
  • Unbundling: Separately billing for procedures that are typically included within a single, primary procedure.
  • Misrepresenting a diagnosis: Falsifying or changing a diagnosis to justify payment for services that might otherwise not be covered.
  • Paying or receiving kickbacks: Soliciting or receiving any form of payment for patient referrals.

Do you suspect fraud, waste or abuse?

Call 800-292-1627 to anonymously report it.

Our Special Investigations Unit continuously monitors for behavior that suggests FWA. Suspect behavior will be subject to audit and may be referred to appropriate regulatory agencies.

Thanks for your cooperation. It’s essential to safeguarding the integrity of our healthcare system.

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