Gulf South Health Plans is committed to providing the best possible healthcare coverage at affordable rates. Healthcare fraud affects providers and consumers alike through higher costs. Please help us eliminate healthcare fraud.

Healthcare Fraud

Gulf South Health Plans Anti-Fraud Unit is headed by the Vice President Medical Affairs and consists of a multi-disciplinary task force dedicated to the detection, elimination, reporting and prosecution of fraudulent activities.

HEALTHCARE FRAUD DEFINED: The National Healthcare Anti-Fraud Association adopted the following definition 11/19/1991:

Health care fraud is an intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, or the entity or to some other party.

The most common kind of fraud involves a false statement, misrepresentation or deliberate omission that is critical to the determination of benefits payable. Fraudulent activities are almost invariably criminal, although the specific nature or degree of the criminal acts may vary from state to state.

The variety of fraudulent reimbursement and billing practices in the health care area is potentially infinite. The most common fraudulent acts include, but are not limited to:

1. Billing for services, procedures and/or supplies that were not provided.

2. The intentional misrepresentation of any of the following for purposes of manipulating the benefits payable:

a. The nature of services, procedures and/or supplies provided;

b. The dates on which the services and/or treatments were rendered;

c. The medical record of service and/or treatment provided;

d. The condition treated or diagnosis made;

e. The charges or reimbursement for services, procedures, and/or supplies provided;

f. The identity of the provider or the recipient of services, procedures and/or supplies.

3. The deliberate performance of unwarranted/non-medically necessary services for the purpose of financial gain.

Reporting of known or suspected healthcare insurance fraud to the Louisiana Department of Insurance is required under state law. Furthermore, fraud involving a beneficiary of a Federally-funded benefit program such as Medicare is aggressively investigated by the Department of Health and Human Services Inspector General's office and may be prosecuted by the United States Attorney's office.

If you are a Gulf South Health Plans beneficiary or Provider and suspect any individual of fraudulent activity as it pertains to benefits under Gulf South, you may contact us by telephone in Baton Rouge at (225) 237-1980 or elsewhere at 1-800-237-3583 or click here to make a report by email. Your submission will be kept confidential. Please include as much information as possible about the nature of the suspected fraudulent activity.