Report Fraud, Waste, and Abuse

AmeriHealth Caritas Next has an established enterprise-wide Program Integrity Department with a proven record in preventing, detecting, investigating, and mitigating fraud, waste, and abuse (FWA). AmeriHealth Caritas Next staff, including a Special Investigations Unit Manager and Investigator, will be supported by the Program Integrity Department.

  • Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law.
  • Waste is the overutilization of services or other practices that result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions, but rather misuse of resources.
  • Abuse is provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the insurance Exchange program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Marketplace insurance program.

The Special Investigations Unit (SIU) team proactively identifies potential incidents of suspected fraud and abuse as part of its program for ongoing monitoring and auditing. 

The SIU investigates allegations such as:

  • Missing documentation of services purportedly rendered;
  • Billing for services not rendered;
  • Alteration or forgery of documentation;
  • Misrepresentation of services provided; and/or
  • Receipt of benefits due to potentially fraudulent actions.

As a network provider, you are responsible for reporting suspected fraud, waste and abuse issues.

Reporting issues to AmeriHealth Caritas Next

If you are aware of a potential or actual fraud, waste, or abuse issue, we encourage you to report the issue to the Special Investigations Unit by:

  • Calling the toll-free Fraud Tipline at 1-866-833-9718, which is available 24/7 and allows for the anonymous reporting of issues.
  • Emailing; or
  • Mailing a written statement to:
    Special Investigations Unit 
    AmeriHealth Caritas Next 
    P.O. Box 7318 
    London, KY 40742

The AmeriHealth Caritas Next Compliance department has implemented a Comprehensive Compliance Program to ensure compliance with all applicable federal and state laws. If you have a compliance or privacy concern, we encourage you to contact our Compliance department. You can report issues to the Compliance department by:

  • Reporting issues to the appropriate entity for the state of North Carolina

    Criminal Investigations Division 
    NC Department of Insurance
    1201 Mail Service Center
    Raleigh, NC  27699-1201
    Phone:  888-680-7684
    Fax: 919-715-1156

Compliance is a shared responsibility and calls upon us to do the right thing in the right way.