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Providers

Fraud, Waste and Abuse Information and Hotline

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male doctor listening to his elderly female patient's heart with a stethescope
Special Investigations Unit (SIU)

Our Special Investigations Unit (SIU) proactively addresses questionable activity and investigates referrals of illegal and unethical conduct. Investigative findings are forwarded to state and/or federal law enforcement agencies for appropriate legal action upon a substantiated finding of misconduct.

Report Suspicious Activity Confidentially

If you suspect illegal and/or unethical activity among our members, employees or providers, call the SIU Hotline at 1-866-477-4848. Each call is evaluated by an investigator. All calls are confidential and may be made anonymously.

Examples of illegal and/or unethical conduct
  • Members selling membership cards or allowing others to use their membership ID numbers to obtain services
  • Members selling medications obtained through the program
  • Members obtaining services or equipment not medically necessary for their conditions
  • Employees selling company information
  • Employees accepting money or gifts in exchange for manipulating parts of any Health Partners Plans' systems/software
  • Providers up-coding claims or submitting claims for services not provided
  • Providers providing false statements to obtain credentials (MediCheck)
  • Providers paying members incentives for patronage
  • Pharmacist paying provider kickbacks for referrals
Addtional Reporting Resources

In addition to calling the SIU Hotline at 1-866-477-4848, you can also report suspected fraud, waste or abuse using the My Compliance Report online reporting tool or by emailing SIUtips@jeffersonhealthplans.com. See below for additional reporting resources:

Frequently Asked Questions

Under the False Claims Act, those who knowingly submit or cause another person or entity to submit false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of a minimum of $11,665 and a maximum of $23,331 (as of June 2020) per false claim.

To learn more about qui tam whistleblower provisions, employee protection, self-auditing and Affordable Care Act expansion of the False Claims Act, please see the "provider billing and reimbursement" chapter of the provider manual.

Fraud refers to any type of intentional deception or misrepresentation, including any act that constitutes fraud under applicable federal or state law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or person, or some other person in a managed care setting, committed by any entity, including the PH-MCO, a subcontractor, a provider, or a member, among others.

Waste refers to the overutilization of services or other practices that result in unnecessary costs. Waste is generally not considered caused by criminally negligent actions, but rather misuse of resources.

Abuse refers to any practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or agreement obligations, including the requirements of state or federal regulations for health care in a managed care setting. Abuse also includes member practices that result in unnecessary cost to the MA Program, the PH-MCO, a subcontractor, or provider.

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