Contact information, policy documents and more

Fraud & Abuse

Fraud, Waste, and Abuse hurts everyone.

It can even raise the cost of getting health care services. This is why we need help from our members and providers to find Fraud, Waste, or Abuse and stop it as soon as possible.

How YOU can help prevent Fraud, Waste and Abuse

As our Member, you play an important role in helping us find Fraud, Waste, or Abuse. If you feel that Fraud, Waste, or Abuse might be happening, report it as soon as you can. Here are some examples of possible fraud:

Someone pretends to be from Gateway Health, Medicare or Social Security and asks for your Social Security number, bank account or credit card numbers, money, etc.
A health care provider offers you cash or gifts to get free medical care
A pharmacy bills you for drugs you did not get, or the pharmacy did not give you the right number of pills ordered by your doctor
You find out someone else is using your health insurance card
You are billed for health care services or items you did not get
Your doctor is ordering a lot of tests or items that you do not feel you need

Payment Integrity Definitions

View and download

Laws and Regulations

View

Provider Fraud, Waste and Abuse Training

View and download

Fraud and Prevention and Detection Plan

View and download

If you suspect Fraud, Waste, or Abuse, call us at 412-255-4340 or 1-800-685-5235 (TTY Users can call 711 or 1-800-654-5984) so we may look into your concerns. You have the option to remain anonymous at all times. You do not have to give your name. Gateway has a team of people who look into all calls or mail regarding possible Fraud, Waste, or Abuse of health care services.

To report Medicare or Medicaid Fraud or Abuse you may contact Gateway by mail or phone at:

Gateway Health Plan
Attention: Payment Integrity
Four Gateway Center, Suite 2100
444 Liberty Avenue Pittsburgh, Pa 15222

Or call the Fraud Hotline at: 412-255-4340 or 800-685-5235

You may also report to the Pennsylvania Department of Human Services (DHS) at:

DHS Bureau of Program Integrity
MA Provider Compliance Hotline
P.O Box 2675
Harrisburg, PA 17105-2675

Or call/fax at: Medical Assistance Provider Compliance Hotline: 1-866-379-8477
Fax: 717-772-4655

You have the option to remain anonymous at all times.

This form is to tell us of suspected waste, fraud or abuse of services paid for by Gateway Health.

Please fill in as much of the information as you can below and click the submit button.

About the suspected member or provider:

First Name: Middle Initial: Last Name: Provider or Practice Name: Phone Number: Street Address: City: State Zip Code:

Tell us about the activity that may be waste, fraud or abuse. Give details that tell us who, what, when, where, why and how. Some examples are:

Billing for services you did not receive

Someone using your identity to receive medical services.

Enter any information about the suspected member or provider:

How can we contact you?

Please provide your contact information so we can contact you is we have questions. Your identity will be protected to the extent allowed. Thank you for helping Gateway Health's efforts to find waste, fraud and abuse.

First Name: Middle Initial: Last Name: Your Email Address: Phone Number: Best time to contact you?:

Keep track of your health services

When you get healthcare services, record the dates on a calendar and save the receipts and statements you get from your doctor to check for mistakes. You should keep track of these things:

Who provided your healthcare	What services you got during the visit and any tests or visits the doctor ordered
Where the healthcare visit took place	The date of your healthcare visit

Keeping track of your health services will not only help you to improve your health, it will also help you to know when there is a problem such as fraud.

Ways to protect yourself from Fraud, Waste and Abuse

Do not give your health insurance card or card numbers to anyone other than your doctor, clinic, hospital or other healthcare provider
Call Gateway as soon as possible if your health insurance card is stolen
Check all bills, statements, or health care information you get. Make sure that the information is correct. If something does not look right, call us as soon as possible so we can look into it
Do not sign your name to any health care forms that are blank
Do not share your medical records with anyone other than your doctor, clinic, hospital or other health care provider