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 Advantageis 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: Billing 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. Billing 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 iswaste? Fraud refers to any willful and deliberate act to deprive another of property or money, through deception or other unfair means. It involves the intent to deceive or make false representations for the purpose of making a profit. 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 serviceand medication history carefully. Make sure the information is correct,and refer anysuspicious claim toTriple-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! 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. How to report possible casesof fraud and abuse? If you have any information or suspicion of a potential case of fraud, waste, or abuse, you may contact us through the following efficient communication methods: Email: email@example.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 Triple-S Advantage, Inc. San Juan, PR 00936 When you call or write,it is important that you provide the following information: Your name, contract number, telephone and addressProviding 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 Your call will be handled in a strictly confidential manner. We will not retaliate, intimidate, or discriminate against you in any way. It is everyone’s responsibility to make good use of the health plan. We all pay for fraud! For more information, you may access the following links: Stop Medicare FraudHow to Prevent Identity TheftPrevent Fraud – Medical Supplies by MailProtect Future GenerationsPrevention and Detection of Financial Exploitation of Senior Citizens and Adults with Disabilities 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 lines of communication: Email: TSACompliance@sssadvantage.com Ethics Point (Available 24 hours / 7 days a week) 1-866-384-4277 secure.ethicspoint.com 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.