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Review the False Claims Policy Guidelines

Health care fraud, waste and abuse are national problems that affect us all. Horizon BCBSNJ takes health care fraud, waste and abuse seriously. The False Claims Policy enforces your obligation as a participating provider to comply with federal and state laws and regulations which prohibit the submission of false claims for reimbursement by the government.

Examples of false claims include, but are not limited to:

  • falsifying medical records submitted;
  • billing for services not rendered or goods not provided;
  • upcoding;
  • revenue-maximizing practices;
  • over-utilization and under-utilization schemes;
  • duplicate billing to obtain double compensation;
  • billing, certifying, or prescribing services that are medically unnecessary.

You and your practice can be sanctioned with civil monetary penalties for the submission of a false claim.  Review the policy carefully for information regarding kickbacks, bribes and other prohibited activities and the consequences for such actions. Please know there are whistleblower protections and incentives to support your duty to report suspected fraud, waste or abuse.

If you suspect that a member, health care professional or employee of a health care facility is committing fraud, call our Special Investigations Anti-Fraud Hotline at 1-800-624-2048 or send documents and/or inquiries to:

Horizon BCBSNJ Special Investigations
PO Box 200145
Newark, NJ 07102-0303

As a Medicare Advantage and Medicare Part D plan sponsor, we also work closely with the Centers for Medicare & Medicaid Services (CMS) to investigate and prosecute all instances of fraud, waste and abuse involving those lines of business. Our dedicated Medicare Advantage and Medicare Part D Fraud, Waste and Abuse Hotline is 1-888-889-2231. You may also send documents and/or inquiries to:

Horizon BCBSNJ Investigations Riverfront Plaza
PO Box 200145
Newark, NJ 07102-0303

All information is strictly confidential.

Published on: June 7, 2021, 04:08 a.m. ET
Last updated on: June 10, 2021, 07:06 a.m. ET