Fraud Waste and Abuse for Members

To report suspected fraud, waste or abuse, you may submit a Special Investigation Referral by completing the on-line form HERE

Fraud, Waste and Abuse

In an effort to improve the healthcare system, NextLevel Health takes the prevention, identification, investigation and remediation of fraud and abuse very seriously. Success in these efforts is essential to maintaining a healthcare system that controls costs to benefit our Members, providers, and tax payers.

What is Fraud, Waste and Abuse?

  • Fraud is generally defined as knowingly and intentionally performing, or attempting to perform, a scheme or ploy to defraud any healthcare benefit program or to obtain (by means of false or deceitful pretenses, representations or promises) any of the money or property owned by, or under the custody or control of, any healthcare benefit program. (18 U.S.C. § 1347)
  • Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.
  • Abuse is payment for items or services when there is no legal entitlement to that payment and the individual or entity has not knowingly and/or intentionally misrepresented facts to obtain payment.

Common fraud schemes

  • Payments or gifts in return for your NextLevel Health ID number
  • Offers for “free” services, goods or equipment in exchange for your NextLevel Health ID number
  • Services billed to NextLevel Health that you don’t remember receiving or didn’t need
  • Receiving multiple tests or procedures that you don’t think you needed or that you feel you are receiving too often
  • Workers or therapists who don’t show up when they are scheduled
  • Workers or therapists who request that you sign-off for hours or services they did not perform

Dos and Don’ts

  • DO ask for a copy of everything you sign.
  • DO be suspicious of anyone offering free tests or screening in exchange for your NextLevel Health ID card number.
  • DON’T give your NextLevel Health ID card or number to anyone except your doctor, clinic, hospital, pharmacy or other healthcare provider.
  • DON’T let anyone borrow or use your NextLevel Health ID card or number.
  • DON’T ask your doctor or other healthcare provider for treatment or care that you do not need.
  • DON’T sign your name to a blank form.
  • DON’T share your medical records or other medical information with anyone except a doctor, clinic, hospital, or other healthcare provider.

How to Report Fraud, Waste or Abuse

If you suspect fraud, waste or abuse, you must report it to NextLevel Health and we will investigate. Your actions may help improve the healthcare system and ensure that together we remain cost efficient.

To report suspected fraud, waste or abuse, you can contact NextLevel Health in one of these ways:

  • You may submit a Special Investigation Referral by completing the on-line form: “CLICK HERE
  • Or you may contact us by:
    • Phone or Fax: 1-888-859-2690
    • E-mail: [email protected]
    • Mail: NextLevel Health, Special Investigation Unit, 224 S. Michigan Ave., Suite 700 Chicago, IL 60604

You have the option to remain unidentified. All information received or discovered by the Special Investigation Unit (SIU) will be treated as confidential, and the results of investigations will be discussed only with persons having a valid reason to receive the information.

NextLevel Health takes all reports of potential fraud, waste and/or abuse very seriously and will investigate all reported issues.

SIU Process

Our investigation process will vary depending on the situation and allegation. Our investigational steps may include the following:

  • Contact with various people to gather information: This may include contacting Members to get a better understanding of the situation.
  • Requests for medical, dental or pharmacy records: We do this to validate that the records support the services billed.
  • Notification of suspected fraud and abuse to the Office of Inspector General and/or law enforcement, if applicable.

To report suspected fraud, waste or abuse, you may submit a Special Investigation Referral by completing the on-line form HERE.