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Protecting Against Fraud, Waste, and Abuse

Georgia Access is focused on protecting consumers, agents, insurance companies, web brokers, and the State of Georgia from instances of fraud, waste, and abuse. Georgia Access coordinates with the Office of Commissioner of Insurance and Safety Fire (OCI) Criminal Investigations Division (CID) to prevent, identify, correct, and report cases of fraud, waste, and abuse.

Fraud, Waste, and Abuse Definitions and Examples

Fraud: Fraud occurs when any person knowingly misstates or misrepresents information to intentionally deceive an individual or system for gain or knowingly provides false information to profit or gain access to an unauthorized service or payment. Examples of fraud might include, but are not limited to:

  • Consumers providing false information to qualify for coverage.
  • An individual knowingly misrepresenting themselves to gain access to a consumer’s financial or other personal information.
  • Insurance companies providing false information with the intent to convince consumers to enroll in a health plan.
  • Agents knowingly enrolling a consumer in a health plan without the consumer’s knowledge or consent.

Waste: Waste is the unnecessary spending or careless use of resources, whether that is intentional or unintentional. Examples of waste might include, but are not limited to:

  • Purchasing items using state funds that are not required or used for business purposes.
  • Billing consumers for a service they did not receive.

Abuse: Abuse is the intentional destruction, manipulation, mistreatment, or misuse of resources or the excessive use of a person’s position or authority. Abuse may occur in financial and non-financial settings and might include, but is not limited to:

  • A provider knowingly or intentionally misrepresenting medical services provided to obtain payment.
  • An employee recording the incorrect hours worked.
  • An individual or entity using grant funding outside the of the authorized scope of use.

How do I report fraud, waste, or abuse?

If you suspect or experience insurance fraud, waste, or abuse, you can report the incident through OCI’s CID online portal.

For more information on how to report suspected insurance fraud to CID, visit the OCI website.

If you suspect fraud, waste, or abuse within Georgia Access, as part of the State of Georgia Executive Branch, you can report the incident through the State of Georgia Office of the Inspector General (OIG). For more information on how to report fraud, waste, or abuse within the Executive Branch of state government, visit the OIG website.

How does Georgia Access handle fraud, waste, and abuse complaints and reports?

As a division of OCI, Georgia Access follows the reporting protocols set by OCI in coordination with the National Association of Insurance Commissioners (NAIC). Upon notification of fraudulent activity, OCI may take legal action against suspected entities. The investigation of fraud claims is handled by the OCI CID.

Insurance Fraud Frequently Asked Questions (FAQs)

Visit the OCI website for more information on insurance fraud FAQs.