What Is Fraud and Abuse?

Fraud is the intentional deception or misrepresentation of material facts with the knowledge that the deception could result in unauthorized benefit or payment for which no entitlement would otherwise exist.

Abuse is practices that are inconsistent with sound fiscal, business or medical practice and result in an unnecessary cost to Renaissance or in reimbursement for services that are not medically necessary, violations of an agreement or certificate of coverage or failure to meet professional recognized standards for health care.

Common Forms of Financial Fraud

Stealing someone’s personal information to commit fraud or theft. This often involves obtaining details like Social Security numbers, credit card numbers, or other sensitive information to open accounts, take out loans, or make unauthorized purchases in the victim’s name, potentially causing long-term financial damage and emotional distress.

Acts committed with the intent to fraudulently obtain payment from an insurer. This includes submitting false or exaggerated claims, staging accidents, or providing misleading information on insurance applications, which can lead to increased premiums for all policyholders and financial losses for insurance companies.

Filing false claims or misrepresenting treatments to receive unauthorized benefits from insurance providers. This includes billing for services not rendered, inflating medical bills, or performing unnecessary procedures, which drives up healthcare costs and can compromise patient care.

Fraudulent claims or misrepresentation to access pension or benefit funds. Perpetrators might falsely claim benefits for ineligible individuals, not report the death of a beneficiary, or provide incorrect information to receive higher benefits, thus draining resources meant for deserving recipients.

Deceptive practices involving financial investments, such as Ponzi schemes. These schemes promise high returns with little risk to lure investors, only to use new investors’ funds to pay returns to earlier investors, eventually collapsing and leaving most participants with significant losses.

Targets seniors through various scams, often via mail or phone. Scammers exploit the trust and vulnerability of elderly individuals, convincing them to provide personal information, send money, or make unwarranted purchases under false pretenses, leading to substantial financial and emotional harm to this demographic.

Using email, websites, or other online means to deceive individuals into providing personal or financial information. Scammers often pose as legitimate institutions to trick victims into sharing passwords, credit card numbers, or Social Security numbers, which are then used for unauthorized transactions or identity theft.

Creating, altering, or using a false document with the intent to deceive others. Common examples include forging signatures on checks, contracts, or identification documents to gain access to money, goods, or services under false pretenses, often resulting in significant financial and legal repercussions for the victim.

Protect Yourself From Fraud

Fraudsters are smart, but you can be smarter. By staying vigilant and proactive, you safeguard not only your financial well-being but also your peace of mind. Taking steps to protect yourself ensures that you remain in control of your personal information and financial resources, preventing potential exploitation and harm.

Fraud Protection Tips

Treat your health benefits card with the same care as a credit card. If it’s lost or stolen, contact Customer Service immediately at 888-358-9484.

After visiting a doctor’s office, an EOB is issued informing you what has been billed. Make sure you had the visit or service on the date stated on the EOB. If anything seems incorrect, call the doctor or healthcare provider for clarification. For help reading an EOB, call Customer Service at 888-358-9484.

Check your credit reports annually, especially if you’ve been denied credit or been the victim of identity theft. The nationwide credit reporting companies must provide you with a free copy of your credit report once every 12 months upon request.

If it seems too good to be true, it probably is. Contact companies using verified methods, not links or numbers from suspicious emails. Type domain names directly into your browser to prevent phishing.

Only provide your SSN when necessary and never in response to unsolicited requests. Don’t carry your Social Security card in your wallet.

Only share financial information when you initiated the contact and know the party you’re dealing with, or when using a verified secure channel (like your member portal).

Regularly update your security software and backup your content. Ensure your operating system, firewall, and virus protection are up to date. When available, enable password protection on your devices, using a PIN, fingerprint or facial recognition.

Use strong, unique passwords for each account, incorporating letters, numbers, and symbols.

Report Fraud and Abuse

Help us combat fraud and keep costs down. If you suspect fraud or abuse, please call our anti-fraud hotline at 888-358-9484 and share a detailed account of the incident or service(s) involved. You can remain anonymous or provide your contact information and request confidentiality.

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