Reporting fraud isn't just your right—it's how you protect the entire benefits system. Fraud costs employers and employees billions every year, driving up premiums and draining money that should go toward real care. Whether you spot an unauthorized charge, a provider billing for services you never got, or someone using your benefits without permission, acting fast matters.
Step 1: Know what counts as fraud or misuse
Before you report, know what actually counts as fraud or misuse. Common examples include:
- Billing for services never performed (e.g., a claim for a procedure you never received)
- Upcoding (charging for a more expensive service than what was delivered)
- Identity theft (someone using your health plan ID card or personal info to get care or prescriptions)
- Phantom dependents (adding ineligible family members to your plan)
- Provider kickbacks (referrals or prescriptions made solely for financial gain)
- Duplicate billing (submitting the same claim to multiple insurers or multiple times)
If you get an Explanation of Benefits (EOB) showing a claim you don't recognize, a bill for a date you weren't at the doctor, or a prescription filled at a pharmacy you never visited, those are red flags.
Step 2: Gather documentation
When you suspect fraud, collect as much evidence as you can before reporting. That means:
- Copies of your EOBs showing the suspicious claim
- Any letters from your health plan, provider, or pharmacy
- Your own medical records or appointment logs (to confirm you weren't there)
- Receipts or statements from the provider or pharmacy
- Dates, times, and names of anyone involved
The more detail you have, the faster investigators can act.
Step 3: Report through the right channel
Where you report depends on the kind of fraud and the type of plan you have. Use this hierarchy:
Employer-sponsored plans
If your benefits come through an employer (which is true for most Americans), start with your HR or benefits department. Many employers have a dedicated fraud hotline or compliance officer. They can flag the issue with the Third-Party Administrator (TPA) or insurance carrier that processes your claims.
Health insurance company (BUCA or self-funded)
Contact your insurance carrier directly. Most major carriers have a fraud reporting line (often called a "Special Investigations Unit" or SIU). Check the back of your insurance card or your plan's member portal for the fraud hotline number. You can often report anonymously.
Government agencies
For fraud involving federal programs or employer-sponsored plans, you can also report to:
- Department of Labor (DOL) – Employee Benefits Security Administration (EBSA): Handles fraud involving ERISA-covered health and retirement plans. Call 1-866-444-3272 or use their online reporting tool.
- Centers for Medicare & Medicaid Services (CMS) – For fraud involving Medicare or Medicaid. Call 1-800-MEDICARE (1-800-633-4227) or the HHS OIG Hotline.
- Federal Trade Commission (FTC) – For identity theft related to healthcare. File a report at IdentityTheft.gov.
- State insurance commissioner – Many states have their own fraud investigation units. Contact your state's department of insurance.
WellthCare ecosystem
If you're on a WellthCare plan (which runs alongside your existing insurance), you can report suspected misuse directly through the WellthCare app or by contacting their compliance team. WellthCare's compliance-grade recordkeeping means every preventive action and reward is verified and traceable, so suspicious activity is easy to spot and report. Since WellthCare tracks preventive actions and reward spending (like Store dollars and Pension deposits), it's especially important to flag any suspicious activity involving those accounts—like unauthorized redemptions or fake preventive scans.
Step 4: Protect yourself after reporting
Once you report, take these steps to safeguard your benefits:
- Request a new plan ID number if you think your identity was stolen. Your employer or carrier can issue a new member ID.
- Review all future EOBs carefully for new unauthorized charges.
- Place a fraud alert on your credit file if personal info was compromised (e.g., Social Security number or birth date).
- Update passwords for your benefits portal and mobile app (like WellthCare's "Wellby" concierge).
You're protected from retaliation under federal law (ERISA Section 510) for reporting benefits fraud. Your employer can't fire or discriminate against you for raising a good-faith concern.
Common myths about reporting fraud
- "It's too small to matter." Every fraudulent claim adds up. Even a single $50 charge contributes to higher premiums for everyone.
- "I'll get in trouble." You're the victim, not the perpetrator. Reporting protects you and your plan.
- "The plan will just ignore it." Most TPAs and carriers have dedicated SIU teams that investigate all claims, and many are legally required to report to state or federal agencies.
As benefits systems get more complex—and platforms like WellthCare change how care and wealth connect—reporting fraud keeps trust intact. It ensures the money meant for your health and retirement doesn't get siphoned off by bad actors.
Final checklist
- Document the suspicious activity (EOBs, receipts, dates)
- Report to your employer/HR first, then to your carrier or the DOL
- Activate protections (new ID, credit alert, password reset)
- Follow up within 30 days for a case number or investigation status
Your vigilance keeps your benefits safe—and helps build a healthier, wealthier system for everyone.