Guidance on Reporting Suspected Fraudulent Billing Activity by Health Care Professionals

The State of New Hampshire Insurance Department 21 South Fruit Street, Suite 14 Concord, NH 03301 David J. Bettencourt Keith E. Nyhan Commissioner Deputy Commissioner BULLETIN Docket #INS 25-084-AB TO: All New Hampshire Licensed Health Carriers and Producers FROM: Commissioner David J. Bettencourt DATE: November 20, 2025 RE: Guidance on Reporting Suspected Fraudulent Billing Activity by Health Care Professionals I. Introduction The purpose of this bulletin is to provide guidance regarding reporting suspected fraudulent billing activity by health care providers. The department previously issued guidance on fraud reporting at Docket No.: INS 22-039-AB. II. Legal Authority Submitting a claim for payment or benefit knowing that it contains any false, incomplete or misleading material information with the intent of deceiving is insurance fraud. See RSA 638:20. In accordance with New Hampshire RSA 417:28, any person or entity regulated by the Department that has reason to believe that an insurance fraud has been committed shall make a report to the Department’s fraud unit within 60 days or within a shorter period under such circumstances as the commissioner may prescribe by rule. The fraud unit will further investigate as it deems appropriate. When a carrier suspects that a participating health care provider, including a health care professional, is engaging in fraudulent activity that is related to claims, or other aspects of managed health care, the carrier must report their concerns to the Department. Carriers will not be in violation of the prompt payment requirements in RSA 420-J:8-a while a claim is pending due to a fraud investigation that has been reported to a state or federal agency. RSA 420-J:8-a, IV (c). Emphasis added. If the carrier anticipates using the suspected fraud exemption to the prompt-pay deadlines, the carrier must report the suspected fraud to the Department by submitting online through the Online Fraud Reporting System (OFRS) through NAIC for the exception to apply. Telephone 603-271-2261 • Fax 603-271-1406 • TDD Access: Relay NH 1-800-735-2964 insurance.nh.gov Claims may be retroactively denied and repayment of fraudulent claims paid by the carrier may be recouped from a provider beyond the 12-month retroactive denial period. RSA 420-J:8-b II, (b) (1). Fraudulent claims must be reported to the Department via the OFRS within NAIC prior to being retroactively denied. Carriers must have standards in place for the investigation of suspected fraudulent activity by health care professionals, including notice to the professionals concerned in order to comply with RSA 417:30. Specifically, the Department requires that carriers have in place written policies and procedures for the detection and investigation of suspected fraud by health care providers. Ins 4601.05. These anti-fraud plans shall be kept confidential by the Department. Ins 4601.07. III. Contact Information For questions or concerns, please reach out to Brenda Golden Hallisey by e-mail at Brenda.M.GoldenHallisey@ins.nh.gov. Page 2 of 2