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Fraud and Abuse

How Health Care Fraud Can Affect You!

CareFirst Medicare Advantage is committed to ensure that its providers - doctors and other health care professionals - are reputable and are able to provide quality care.  In addition, CareFirst Medicare Advantage takes its responsibilities towards reducing cost, preventing waste, and uncovering potential fraud very seriously. That is because we empower all our employees and contractors to find, reduce, eliminate, or report fraud, waste, and abuse.  However, there is always a possibility that a provider, or a consumer, will engage in unethical, potentially fraudulent practices. Even a single fraudulent claim can raise the cost of health care benefits for everyone.

What is health care fraud?

Health care fraud is a crime. Healthcare fraud means to deceive another, like a private insurer, by intentionally misrepresenting or concealing a material fact(s) in order to obtain money or property, such as health care coverage or benefits. Fraud takes many forms, and can include direct misrepresentations as well as half-truths and the knowing concealment of facts. Some examples of provider health care fraud are:

 Health Care Fraud,Waste and Abuse can take many forms.  Some common types of health care fraud, waste and abuse include:

  • Intentionally misrepresenting facts regarding the payment of benefits
  • Routinely waiving co-payments or deductibles
  • Billing for medically unnecessary items or services
  • “Unbundling” claims, or separate billing procedures instead of using a more appropriate global billing procedure
  • Providing treatment that is inconsistent with the diagnosis
  • Withholding medically necessary services
  • Upcoding claims, or billing at a higher rate than is appropriate for the item or
  • service provided
  • Misrepresenting facts affecting eligibility for benefits, such as: employment status, health history, marital or student status, identity.
  • Forging or altering bills or receipts; or
  • Using someone else's coverage, personal information or insurance card

Help avoid and prevent health care fraud.

Here are some easy ways you can protect yourself from health care fraud, and keep health care costs down for everyone.

  • Ask questions about the services you receive, such as: Why are they needed? What do they cost?
  • Beware of advertisements or promotions that offer free tests, treatment or services - especially when the provider requests your insurance information or a copy of your CareFirst Medicare Advantage ID card.
  • Question charges exceeding your copayment amount that you're asked to pay by a provider.
  • Let us know if a provider has a practice of waiving copayments or deductibles.
  • Report suspected fraud to Special Investigations.
  • Be careful about disclosing your insurance information. Do not give out your policy numbers to door-to-door salespeople, telephone solicitors or over the Internet. Protect your CareFirst Medicare Advantage ID card like you would your credit cards. It represents your benefits.
  • Compare your CareFirst Medicare Advantage- Explanation of Benefits (EOB) and/or your medical prescription drug receipts with your records. Are the dates of service correct? Were the services actually performed?

Don't be a victim of identity theft.


  • No one should call you or come to your home uninvited to sell Medicare products.
  • Medicare plans cannot ask you for credit card or banking information over the telephone unless you are already a member of that plan.
  • In most cases, Medicare can’t call you to enroll in a plan—you must call them.
  • Only give your information to doctors, other providers and plans contracted by Medicare, and to people in the community who work with Medicare, such as your State Health Insurance Program (SHIP) or Social Security.

If you think you've been a victim of identity theft or fraud:

Call any of these numbers:

  • Call toll-free 1-800-MEDICARE (1-800-633-4227). TTY, call toll-free 1-877-486-2048, 24 hours a day, 7 days a week.
  • The Fraud Hotline of the HHS Office of Inspector General, toll-free at 1-800-HHS-TIPS (1-800-447-8477). TTY, call toll-free 1-800-377-4950. You can also email
  • The Federal Trade Commission's ID Theft Hotline toll-free at 1-877-438-4338 to make a report. TTY users, call toll-free 1-866-653-4261.

CareFirst Medicare Advantage is working to minimize health care fraud.

Our Special Investigations Unit (SIU) is responsible for minimizing CareFirst Medicare Advantage's risk of health care fraud. The SIU partners with CareFirst Medicare Advantage's and our contractors’ Member Services, Provider Network and Claim Departments to help identify suspicious claims, stop payments to fraudulent providers and punish wrongdoers.

The SIU also works with state and federal law enforcement, regulatory agencies and other insurance companies to detect and prevent health care fraud and assist in the pursuit of restitution and/or prosecution of health care fraud offenders.

How to report potential cases of fraud

To report a potential case of fraud, call CareFirst Medicare Advantage’s dedicated compliance line at (410) 779-9323, 24 hours a day, 7 days a week. TTY users may call 711.

This hotline allows you to report cases anonymously and confidentially.  CareFirst Medicare Advantage will make every effort to maintain your confidentiality. However, if law enforcement needs to get involved, CareFirst Medicare Advantage may not be able to guarantee your confidentiality. Please know that CareFirst Medicare Advantage will not take any action against you for reporting a potential fraud case in good faith.

You can also email us at or write to us at:

CareFirst BlueCross BlueShield Medicare Advantage
Medicare Compliance
1966 Greenspring Drive, Suite 100
Timonium, Maryland 21093

For potential medical or non-prescription fraud cases, you may report to the Medicare program directly, toll-free, at 1-800-Medicare (1-800-633-4227). The Medicare fax number is 1-717-975-4442 and the website is

For more information, request the guide titled “Protecting Medicare and You from Fraud” by calling toll-free 1-800-Medicare (1-800-633-4227). TTY/TDD users should call toll-free 1-877-486-2048. A customer service representative can answer your questions 24 hours a day, 7 days a week.