Fraud & abuse
Member fraud and abuse
Fraud can be:
- Lying or holding back information when you sign up to be a member of an Aetna Medicare Advantage Dual Eligible Special Needs Plan
- Letting someone else use your Aetna® ID card
- Not telling the Social Security Administration (SSA) or the Department for Community Based Services (DCBS) about changes in income and family status
- Not telling the Virginia Department of Medical Assistance (DMAS) that you have other insurance
Abuse can be:
- Too many emergency room visits for conditions that are not emergencies
- Using pain medicines that you do not need
- Getting prescriptions that you do not need
If you commit fraud or abuse, you:
- Must pay back any money paid for you to get services
- Could be prosecuted for a crime and go to jail
- Could lose your Virginia Medicaid benefits for up to a year
Providers can commit fraud many different ways. Provider fraud, like member fraud, takes money from those who need it. Because of this fraud, there is less money to treat members who need medical help. You can help stop provider fraud.
Keep a record of:
- Medical services you get
- When and where the service takes place
- Name of the person who takes care of you
- Any other services ordered by the provider
Some examples of provider fraud are:
- Billing for services that you did not get
- Making an appointment for a return office visit when you do not need one
- Taking x‑rays, doing blood work, etc. that you do not need
- Billing for services that someone else in the office actually performed (charging you too much for those services)
- Billing for more time than the service took
- Adding extra names to your bill (for example, a family member) and billing for those
- Taking money from another provider to refer you to him/her
Fill out the form below or call 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven days a week to report suspected fraud or abuse of services paid for by Aetna. You do not have to give your name when you report fraud or abuse.
Even if you provide your contact information, your identity will be kept confidential.
Please complete as much of the requested information as you can below.