Stop Medicare Fraud

Fraud, waste, and abuse

Health insurance fraud, waste, and abuse affect us all. Help us detect it!


Fraud, waste, and abuse affect you as a plan beneficiary, as well as health plans and service providers. Health resources are sometimes limited, and it is important that they be used appropriately. Using resources inappropriately may result in a lower quality of medical services.

Therefore, it is important that any illegal or fraudulent act is reported immediately.

Triple-S Advantage
is committed to reducing and controlling the incidence of fraud, waste, and abuse in the health insurance industry.

For this purpose, our organization has a team of trained professionals with investigative experience who interact with local and federal agencies, as well as other insurance companies to detect, prevent, investigate, and process cases of fraud, waste, and abuse.

What is fraud?

Fraud refers to any intentional and deliberate act to deprive another of property or money,
through deception and other unfair means. It involves the intent to mislead or make false representations to obtain personal gain.

For example:

What is fraud?

Fraud refers to any intentional and deliberate act to deprive another of property or money,
through deception and other unfair means. It involves the intent to mislead or make false representations to obtain personal gain.

Dont Frau!
For example:
  • Invoicing for services and procedures that were not rendered; billing for supplies or medications that were not dispensed.
  • Lending the health insurance ID card to another person to obtain clinical services or medications.
  • Billing of a more complex service (more costly) than the one that was rendered to obtain a larger payment (upcoding).
  • Submitting false documents in order to obtain reimbursements.
  • Invoicing for the same service more than once.
  • Submitting a health plan enrollment application containing false information.
  • Billing a full prescription when it was not dispensed in its entirety.
  • Making false representations of products or plan benefits or of the enrollment process.

What is
waste?

It is inappropriate or careless use, consumption or waste of resources or benefits.

For example:

A physician (unaware that there is a generic alternative) consistently prescribes a high-priced medication instead of the less expensive drug available in the formulary.

What is
abuse?

It is defined as
the excessive and improper use of resources or services, in a manner contrary to usual practices to obtain personal gain. This results in unnecessary costs for the health care system.

For example:
  • Overuse of services or rendering of unnecessary clinical services
  • Ordering of diagnostic tests that are not medically justifiable
  • Payment for services that do not comply with generally accepted health care standards.
  • An employee using corporate resources for personal use not related to work.

What can I do to prevent
fraud and abuse?

Read your service
and medication history carefully. Make sure the information is correct,
and refer any
suspicious claim to
Triple-S Advantage

Protect your health plan ID card as if it were a credit card.
Never offer information about your health plan to solicitors over the telephone or unknown persons

Get acquainted with the terms of your coverage and keep copies of medical tests to avoid redundant services.

If you visit several doctors, save a copy of your labs and other test results, and keep a handy list of the medications that you take. This way, you won’t have to repeat time-consuming and costly tests. Take a more proactive stance in your health care!

Term

Get acquainted with the terms of your coverage and keep copies of medical tests to avoid redundant services.

If you visit several doctors, save a copy of your labs and other test results, and keep a handy list of the medications that you take. This way, you won’t have to repeat time-consuming and costly tests. Take a more proactive stance in your health care!

Check the information before signing any insurance application or health service claim.
Never sign a blank enrollment form. Make sure you know exactly what you are signing.

Beware of “free” medical services, as illicit entities use this lure to obtain information.

phone

How to report possible cases
of fraud and abuse?

If you have any information or suspicion of a potential case of fraud, waste, or abuse, you may contact our Compliance Department, Fraud and Abuse Unit through the following efficient communication methods:

Ethicspoint

Email: fraude@ssspr.com
Phone: 787-277-6633
Secure Fax: 787-625-8700
Internet portal:
https://secure.ethicspoint.com/domain/en/report_company.asp
(Once you access the portal, please select Triple-S Management Corporation)

Postal Address

Correo Postal

How to report possible cases
of fraud and abuse?

If you have any information or suspicion of a potential case of fraud, waste, or abuse, you may contact our Compliance Department, Fraud and Abuse Unit through the following efficient communication methods:

Ethicspoint

Email: fraude@ssspr.com
Phone: 787-277-6633
Secure Fax: 787-625-8700
Internet portal:
https://secure.ethicspoint.com/domain/en/report_company.asp
(Once you access the portal, please select Triple-S Management Corporation)

Postal Address

Correo Postal
  • Your name, contract number, telephone and address
    Providing us your contact information is optional. You may file your report anonymously. However, providing your information could help us if we need to obtain any additional details about your referral
  • Name of the person or entity that incurred in the potentially fraudulent action
  • Summary of the suspicious act (including dates and what the act is)
  • Manner in which you obtained the information or how you became aware of the suspicious act
  • Documents that you can provide to aid in the investigation

Code of Business Conduct and Ethics

Grupo Triple-S has a Code of Business Conduct and Ethics, which establishes the Corporation’s commitment to ethics and compliance with federal laws and regulations and the Commonwealth of Puerto Rico. In addition, it describes compliance expectations for all employees, members of the Board of Directors, subcontracted and related entities.

Read the Code of Business Conduct and Ethics, it guides you to know what to do in situations of compliance, fraud, waste or abuse.


Download PDF Document

If you are aware or suspect of compliance, fraud, waste or abuse situation, contact the Triple-S Advantage Compliance Department through the following effective communication hotlines:

Email: TSACompliance@sssadvantage.com
Ethics Point (Available 24 hours / 7 days a week)

Triple-S will not discriminate or permit retaliation or intimidation against any person who conducts a report in good faith or participates in an investigation into violations of the Code of Business Conduct and Ethics.

Get in touch with our experts:

Sales Representative

1-877-207-8777

TTY/TDD Users

Monday through Friday
from 8:00 a.m. to 8:00 p.m.

I am undecided. Please call me to provide some guidance.

By completing this form, you as a beneficiary or authorized representative agree to have one of our sales representatives contact you to discuss the products Triple-S Advantage offers under Part C. Please be aware that the person calling you is a Medicare employee or subcontractor. They do not work directly with the federal government. This person could receive compensation based on your plan enrollment.

This selection does NOT obligate you to enroll in a plan, it does not affect your current membership, and it will not enroll you in another Medicare plan.

Get to Know Medicare

Member Service

1-888-620-1919

TTY/TDD users

1-866-620-2520

Monday thru Sunday, from 8:00 am to 8:00 pm

Service for Providers

1-855-886-7474

Monday thru Friday, from 8:00 am to 5:00 pm

Teleconsulta

1-800-255-4375

Teleconsejo

1-877-879-5964

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