Fraud, Waste, & Abuse

Protecting the integrity of our health plans and the
healthcare system is a shared responsibility.

Reports may be made anonymously
and will be handled as confidentially
as reasonably possible.

At Elan Insurance Group, we are committed to preventing, detecting, investigating and addressing suspected fraud, waste and abuse (FWA). We encourage members, providers, employees, business partners and others to report activity they believe may involve FWA.

What Is Fraud, Waste & Abuse?

FRAUD

Intentionally providing false or misleading information or engaging in deceptive conduct to obtain an unauthorized benefit or payment.

WASTE

The unnecessary use or misuse of healthcare resources that results in avoidable costs, including inefficiencies, billing errors or overutilization.

ABUSE

Practices inconsistent with accepted healthcare, business or billing standards that may result in unnecessary costs or improper payments.

Who Should Be Watching?

MEMBERS

Help protect your benefits and personal information by reviewing your Explanation of Benefits (EOB) and confirming that services and charges match the care you received.

Watch for:

  • Services, equipment or prescriptions you did not receive
  • Someone using another person’s health plan information
  • Requests for insurance information in exchange for gifts or incentives
  • Charges that do not match the services you received

PROVIDERS

Providers should maintain accurate records and submit claims that appropriately reflect the services provided.

Potential concerns include:

  • Upcoding: Billing for a higher-level service than was provided
  • Unbundling: Separately billing services that should be billed together
  • Billing for services not provided or medically unnecessary
  • Improper incentives related to referrals or healthcare services
  • Altering or falsifying medical documentation

EMPLOYEES

Every Elan employee is expected to follow applicable laws, company policies and compliance procedures and promptly report suspected misconduct.

Potential concerns include:

  • Falsifying company, member, provider or financial records
  • Knowingly approving improper or fraudulent claims
  • Circumventing required controls or compliance procedures
  • Concealing compliance concerns or misusing confidential information

Non-Retaliation

Elan prohibits retaliation against anyone who, in good faith, reports suspected fraud, waste, abuse or another compliance concern or participates in an investigation.

Report Fraud, Waste or Abuse

If something appears suspicious, please report it. You do not need proof to report a concern. Providing as much detail as possible—including names, dates, claim information and a description of the activity—helps us review your concern.

Reports may be made anonymously and will be handled as confidentially as reasonably possible.