Fraud and Abuse

Fraud is everyone’s business

Health care fraud affects all of us —from small businesses to corporations, insurers, doctors and members. It impacts the quality of health care and results in higher costs.

What can you do?

Know what to look for. Be suspicious if providers of medical or dental services or supplies:

Bill significantly more than other doctors for treatment you’ve had in the past
Offer treatment while promising you won’t have to pay the balance due after insurance pays
Offer to bill your insurance for services that weren’t performed in order to cover your out-of-pocket costs
Bill for treatment you haven’t received yet
Bill insurance when you used a coupon for “free services”
Bill insurance for services or equipment you did not get, want or request
Order what appear to be more tests than are necessary
Want you to bring other family members with you to your appointments to treat them for the same condition, even if they don’t have the same medical complaints as you
Ask you to fill a prescription and bring the medicines back to their office
Call to offer you “free” medical equipment your doctor didn’t order
Call to offer getting certification for medical equipment neither you nor your doctor previously discussed using

Also, be suspicious if you get shipments of medication, creams or other supplies you didn’t order nor do you want.

Here's how to protect your benefits and your identity:

Know who you’re sharing information with

If you're an Aetna member: Give your member ID number not your Social Security number when you go to the doctor, dentist or hospital.
Don’t be afraid to ask questions if someone asks for your personal information.
Never give out your Social Security number, Medicare ID number, health plan ID number or banking information to anyone you don’t know.
Beware of suspicious phone calls. Confirm who is calling and ask for a call back number.

Make sure your plan statements are correct

If you get a bill for something that doesn’t look correct or that you didn’t receive, let us know. Carefully review your statements to:

Make sure you received the services or items on your bill.
Check the number of services or items on your bill.
Be sure that the same service isn't on your bill more than once.
Verify that the copayment amount is correct.

Talk to your doctor about what items and services you need

Beware of people calling on behalf of your doctor. Hang up and call your doctor’s office to verify.
Don’t accept delivery of drugs, creams, supplies or braces unless you spoke to your doctor about them.

Free services don’t require you to give out personal information

Don’t accept items or services you don’t want. This includes medications, creams or supplies that are mailed to you.
If someone offers you a free service, they shouldn’t ask for your health plan ID number, Social Security number or Medicare ID number.

Remember: If the deal is too good to be true, it probably is!

If you see something suspicious or have a question about your plan statement, call us at the number on your ID card.

Suspect fraudulent activity? Call our hotline at 1-800-338-6361 (TTY: 711) or email us at AetnaSIU@aetna.com

You can always report your concerns anonymously. Aetna is a CVS Health Company. To report your concerns to us anonymously, contact the CVS Health EthicsLine.

There are many different types of fraud, waste and abuse. It’s important to be able to identify these issues. This protects your identity and benefits.

Online theft of personal information

People may try to steal your personal or insurance information online. They can harm you financially. They may also disrupt your benefits. It’s not always easy to tell the difference between an important email about your benefits and an online scam. An email may say there’s a problem with your account. Or it may ask for updated information to continue your coverage.

What you can do:

Delete or ignore suspicious emails. Don’t click on links or download attachments.

- Legitimate email addresses usually end in .com, .org or .gov.
- Beware of emails with misspellings or bad grammar.

Don't give personal or financial information by email.
Update your antivirus software regularly. Set up filters for junk or spam email.
When in doubt, call us at the number on your health plan ID card.

Fake discount cards for prescriptions

Discount prescription drug cards can save you money. But some scammers use fake discount cards to steal your identity or your money. Real discount cards are free you should never pay for one.

What you can do:

Talk to sources you trust, like your health plan and pharmacist.
Avoid discount cards that ask for money or claim to replace your current coverage.

Telemarketing scams

Many legitimate businesses use telemarketing. But criminals can also use live or recorded calls to try to steal your identity. Aetna won't call to ask for your bank account number, Social Security number, or other identifying information.

What you can do:

Hang up on recorded messages that ask you to verify your personal information.
Don't press any keys or numbers when prompted — even if it's to take your name off their list.
Never give your personal information to someone you don’t know.
Report suspicious numbers to the Federal Trade Commission at 1-888-382-1222 (TTY: 711).

Online pharmacy scams

Most online pharmacies aren't safe or legal. They might send you medicine that's tampered with, expired or fake. They could use your personal information to steal your identity.

What you can do:

Only order from online pharmacies in your health plan’s pharmacy network
Don’t click on links in emails or pop-up advertisements on the Internet
Don’t order from pharmacies outside the United States
Report pharmacies that:

- Offer prescription drugs without a prescription
- Won’t accept your prescription insurance card as a form of payment

Home health agency fraud

Home health services are only medically necessary if you’re confined to your home. Some home health agencies may take advantage of you and commit fraud.

What you can do:

Make sure that your doctor authorized your home health services.
Make sure that your bill is for the number and type of home health visits you received.

Medical transport services fraud

Medical transport services are sometimes necessary. Some companies may bill your insurance for services you didn't receive. Services, such as Basic Life Support (BLS), includes oxygen, cardiac (heart) monitoring and more.

What you can do:

If your bill shows BLS but you did not receive these services report it!

Medical supplies fraud

If you get supplies that you or your doctor didn't order, you might be the target of a fraud scheme.

What you can do:

Refuse medical supplies that you didn't order.
Return any medical supplies that are shipped to your home if you didn't order them.
Report the company that sent them.

Lab test fraud

Beware of “free” laboratory tests, like cheek swabs or blood tests. Someone may be trying to steal your identity or submit a fraudulent bill.

What you can do:

Never accept a free test if you are asked for your health plan ID number, Social Security number or other identifying information.
Talk to your doctor about what test you need, and make sure we cover it.