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Fraud, Waste, and Abuse (FWA)

Health care fraud costs taxpayers about $36 billion a year. When providers or members misuse or mismanage resources, the resulting costs are detrimental to our mission and our government partners.

AmeriHealth Caritas has made health care fraud prevention and detection a primary emphasis. Across the enterprise, we are increasingly focused on preventing improper payments rather than a "pay and chase" method of recovery.

Oversight and compliance

AmeriHealth Caritas has numerous processes in place system-wide—all designed to prevent and detect FWA. They include:

Preventive actions

  • Multiple front-end audits.
  • High-dollar claim pre-disbursement reviews.

Post-payment actions

  • Medical claims data checks.
  • Payment trend analysis.

Special Investigations Unit (SIU)

  • Anti-fraud software helps identify FWA patterns.
  • Claims data analyses help identify improper payments.
  • Pharmacy audits.

Reporting FWA

All cases of suspected FWA are reported to the state Medicaid oversight entity and applicable law enforcement agencies.

To report suspected FWA, contact AmeriHealth Caritas' SIU at 1-866-833-9718.