CHIP Fraud and Abuse

Health-care billing mistakes happen a lot. The rules that doctors and hospitals must follow are very tricky. Mistakes also happen because the doctor’s office or emergency room is just really busy. Most doctors and hospitals want to do what is right. They want to follow the rules and take care of your family.  

But, you may have read about hospitals and providers that have cheated the system. They billed for services they did not do, or worse. We need your help to stop this. Texas Children’s Health Plan has been authorized by the State of Texas to implement a program to identify and prevent fraud, abuse, and waste. These terms mean:  

• Fraud - Knowingly submitting false claims in order to receive payment.
• Abuse - Taking advantage of loopholes in the law to increase payments.
• Waste - Making excessive payments due to poor training and education.

Fraud, abuse, and waste hurt everyone. It raises taxes. It reduces funds available to pay benefits. It may even reduce the quality of care.

Some examples of fraud you might see include:  

• Providers billing for services your family did not receive.
• Billing for different services than what you received.
• Asking for your Member ID number when you are not going to the clinic or hospital.
• Offering money for your Member ID number.
• Offering prizes or payments for you to come to a clinic or hospital.

Be on the lookout for common scams such as:  

• Statements that “Your health plan wants you to have this service.”
• Telemarketing or door-to-door salespeople offering medical services.
• Saying that the more tests that are done, the cheaper they are for the government.

To help us prevent fraud, follow some of these tips:  

• Don’t give out your Member ID number to anyone you do not know.
• Only give it to your doctor or hospital.
• Don’t ask for services you don’t need.
• Be careful of anyone saying “The services are free, so you should use my clinic.”

Can members commit fraud?  

Some members do commit fraud. They might change doctors to feed a bad habit. They might ask for services they do not need or they may lie to a doctor. Some may even work with a doctor to commit fraud in return for money. Member fraud is against the law. Member fraud could result in losing your benefits. It could also mean fines or jail.  

If you suspect fraud, abuse, or waste  

What if you suspect fraud? Contact us immediately. Do not wait more than one day.  

Texas Children’s Health Plan’s fraud hotline is 1-832-828-1320. The fax number is 1-832-825-8772. You can e-mail us at TCHPSIU@texaschildrens.org  

Or send a letter to:  

Texas Children’s Health Plan
Fraud and Abuse Investigations
Mail Code WLS 8360
PO Box 301011
Houston, TX 77230-1011  

You do not have to give your name. Just tell us why you think there is fraud. Give us the name of the provider and tell us what you are worried about. We will take your concerns seriously. We will investigate every case. We may even send your concern to the State. Most often, we will teach the provider what they did wrong.  

Please help us  

Texas Children’s Health Plan wants to identify and prevent fraud. We need and appreciate your help. Call us with any questions.