Preventing Fraud

HIPAA (The Health Insurance Portability and Accountability Act of 1996) is legislation that provides privacy and security provisions for safeguarding medical information. HIPAA establishes national standards to protect personal or protected health information (PHI).

PHI includes:

• A name, address, birth date, or social security number
• An individual’s physical or mental health condition
• Any care provided to an individual
• Information concerning the payment for the care provided to the individual that identifies the patient, or information for which there is a reasonable basis to believe could be used to identify the patient.

Fraud is generally defined as intentional misuse of information in an effort to receive an unauthorized benefit. Waste involves using, consuming, or spending thoughtlessly or carelessly. Abuse involves improperly using program resources for personal gain.

Here are some examples of fraud, waste, and abuse:

• A provider billing for medical services or items that were not ordered or provided
• A provider providing services or items that a person does not need or are not medically necessary
• A provider billing for services that are more complex than what was actually performed, resulting in higher costs
• A patient who may or may not be ill seeing doctor after doctor in order to obtain multiple prescriptions for painkillers
• A member receiving suspicious phone calls asking for personal health information

Reporting Compliance, HIPAA, and Fraud, Waste, and Abuse Concerns

If you encounter a HIPAA concern or suspect fraud, waste, or abuse in the healthcare system, you can report it to Quartz, and we will investigate. To protect yourself from fraud, review any bills that you receive from healthcare providers. If you see something that does not look right, you should report it.

To report any suspected concerns, you can contact Customer Service:

• Local telephone number: (608) 881-8271
• Toll free telephone number: (800) 897-1923
• TTY / TDD: 711 or (800) 877-8973
• Email address: customerservice@quartzbenefits.com

You can also report to the Compliance Hotline:

• Local telephone number: (608) 644-3495
• Toll free telephone number: (844) 492-2996

Callers may remain anonymous, if preferred. All information will be kept strictly confidential to the fullest extent possible. No retaliatory action will be taken or will be allowed against any person who reports potential issues in good faith. Once an issue is reported, Quartz will begin an investigation and will report to the appropriate authorities, if necessary.