Insurance Fraud Frequently Asked Questions
Reporting Health Care or Insurance Fraud and Abuse
Fraud is the intentional misrepresentation of a material fact that is relied upon by the victim, which results in the loss of property, usually monetary. This can include payment for health care services induced by fraud.
Health care abuse usually means any activity that unjustly robs the health care system – in our case, Rocky Mountain Health Plans (RMHP) – but does not constitute fraud. A provider may obtain payment for health care services to which he/she is not entitled, but there is not the intent to deceive as there is with fraud.
Examples of consumer fraud include:
- Fraudulent omission or misrepresentation of medical information or history on the application
- Fraudulent eligibility of dependents
- Fraudulent submission of claims
- Altering prescriptions
- Using another Member's card to obtain health care services
Examples of provider fraud include:
- Falsifying recipient identities
- Padding, or overstating health care charges
- Upcoding, or charging for similar but higher priced services
- Billing for services that were not provided
- Asking for, offering, or accepting kickbacks
- Performing noncovered services but billing for covered services
General complaints or unhappiness with a provider or RMHP are not examples of fraud. See how to handle these kinds of matters by reading your Health Benefits Contract.
RMHP is committed to preventing, detecting, investigating, and prosecuting health care or insurance fraud. If you think someone is doing something wrong or illegal with regards to their Rocky Mountain Health Plans health care or insurance, please call:
Fraud Hotline
970-248-5101
888-237-1179
Or you may write:
Fraud Investigator
Rocky Mountain Health Plans
PO Box 10600
Grand Junction, CO 81502-5600
Or you may e-mail:
fraudauditor@rmhp.org
Tell us what you know about the reported situation, either one that has happened or that is still happening.
- Who is involved?
- What are they doing?
- When is it happening?
- Where is it happening?
- Why is it happening?
- How is it happening?
Medicare Part D; CMS Required Training - Fraud Waste and Abuse (FWA)
Medicare Part D is a federal program used to subsidize the cost of prescription medication to Medicare beneficiaries. It was enacted as a part of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) that became effective January 1, 2006. The MMA requires Rocky Mountain Health Plans (RMHP) create and distribute Part D fraud, waste and abuse (FWA) training information. That training is required to be completed by RMHP employees as well as downstream and first-tier entities no later than December 31, 2011, upon hire or contract, and annually thereafter.
Download more information
Begin Training
Fraud, Waste, and Abuse Attestation for Pharmacy Providers
The bottom line on fraud
Health care and insurance fraud and abuse costs each one of us – estimated at more than $100 billion annually in the United States alone. The majority of frauds are discovered and stopped because someone got involved and reported the wrongdoing.
Use the Fraud Investigation Referral Form to send RMHP some of the information necessary to conduct a proper fraud investigation. Thank you for your help.
