Stop Medicare Fraud

Triple-S Advantage is committed to reducing and controlling the incidence of fraud, waste, and abuse in the health insurance industry. Health insurance fraud, waste, and abuse affect us all. Help us detect it!

Fraud, waste, and abuse

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.

  • Fraud

    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.
    • Submitting false documents in order to obtain reimbursements.
    • Intentionally 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.
  • Waste

    What is waste?

    Practices that directly or indirectly, result in unnecessary costs to the health care programs, caused by the misuse of resources.

    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.
    • Inappropriate frequency of services
    • Specialty Pharmacy delivered an infusion drug, but the patient does not continue with the treatment
  • Abuse

    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
    • Billing excessive diagnostic tests without clinical justification.
    • Waiving cost sharing amounts.

What can I do to prevent fraud and abuse?

Step 1

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

Step 2

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.

Step 3

Get familiarize 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!

Step 4

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.

Step 5

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

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 us through the following efficient communication methods:

Your call will be handled in a strictly confidential manner.
We will not retaliate, intimidate, or discriminate against you in any way.

Additional information

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:

  • Service for Providers1-855-886-7474
  • Monday thru Friday, from 8:00 am to 5:00 pm