Fraud and Abuse

Health insurance fraud and abuse affects us all! Help us detect it!

Fraud affects us all: people who purchase insurance, health plans and service providers. Health resources are limited and it is important that they be used appropriately. Using resources inappropriately results in an increase in insurance premiums and a lower quality of medical services.

Therefore, it is important that any illegal or fraudulent act is reported immediately.

Triple-S Salud is aware of the impact of fraudulent acts and abuse of services at the local and national level, and it is committed to reducing and controlling the incidence of fraud and abuse in the insurance industry. For this purpose, the corporation has a team of trained professionals with investigative experience who interact with local and federal agencies and other insurance companies to detect, prevent, investigate and process cases of fraud.

What is fraud?

Fraud refers to any intentional and deliberate act to deprive another of property or money, through deception and other unfair means. It involves the intent to mislead or make false representations to obtain personal gain for oneself or others.

Some examples are:

  • Filing claims for services and procedures that were not rendered; billing of supplies or medications that were not dispensed.
  • Lending the health insurance ID card to another person to obtain clinical services or medications.
  • Billing of a more complex service (more costly) than that which was rendered, to obtain a larger payment (upcoding).
  • Submitting false documents in order to obtain insurance reimbursements.
  • Billing of the same service more than once
  • Submitting a health plan enrollment application containing false or incomplete information.
  • Billing a full prescription when it was not dispensed in its entirety.

What is abuse?

It is defined as the excessive and improper use of a product, service or benefit, or the use of something in a manner contrary to usual practices. This results in unnecessary costs for the health care system.

Some examples are:

  • Overutilization of services or rendering of unnecessary clinical services.
  • Excessive ordering of diagnostic tests that are not medically justifiable
  • Not collecting copayments or coinsurance payments as a strategy for attracting customers.

What can I do to prevent fraud and abuse?

Read your claims carefully: Refer any suspicious claim to Triple-S Salud. Inc.

Protect the information on your ID card: Never offer information about your health plan to solicitors over the telephone or to unknown persons.

Get acquainted with the terms of your coverage and keep copies of medical tests to avoid repeating services. If you visit several doctors, save a copy of labs or other test results and bring a list of the medications that you take. This way, you won’t have to repeat time-consuming and costly test.

Check the information before signing any insurance application or health service claim to make sure it is correct.

How to report possible cases of fraud and abuse?

If you have information or suspect that health insurance fraud or abuse may have been committed, you can contact Triple-S Salud through the Fraud and Abuse confidential line at (787) 277-6633, Monday through Friday from 8:00 AM to 4:30 PM. If you want to report it in writing, you can follow this link to the Referral of Possible Cases of Fraud and Abuse Form at the Triple-S Salud website. You can also contact us by:

Fax at (787) 625-8700
Post office mail:
Triple-S Salud, Inc.
Audit and Investigation Office
PO Box 363628
San Juan, PR 00936-3628
E-mail: fraude@ssspr.com

When you call or write it is important that you provide the following information:

a. Your name, contract number, telephone and address (this information is optional and will be used to contact you if necessary)

b. Name of the person or entity under suspicion

c. Summary of the suspicious act (dates and what it is)

d. Manner in which you obtained the information or how you became aware of the suspicious act

e. Documents that you can provide to aid in the investigation

Your call will be handled in a confidential manner. If the results of the investigation carried out by the company reveal the perpetration of an act of fraud, it will be referred to the appropriate authorities.

It is everyone’s responsibility to make good use of the health plan. You pay for fraud!

Keep me informed

In Triple-S Advantage we want to inform you about important health topics.

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