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Health Care Fraud & Awareness

Health care fraud is a serious issue and it can affect everyone, including you.
It is estimated at least three percent of health care dollars are lost to fraud each year. This may be a small percentage compared to the $2 trillion dollars the U.S. spends on health care annually, but it raises the cost of health care benefits for everyone.

What is health care fraud?
Health care fraud is the intentional misrepresentation of information to gain undeserved payment for a claim.

What is abuse?
Abuse involves a questionable practice, which is inconsistent with accepted medical or business policies. Although it is not an intentional misrepresentation, it may result in unnecessary costs.

Who can commit fraud or abuse?

  • Members
  • Patients
  • Health care providers, including doctors, hospitals, clinics, labs, etc.
  • Employer groups
  • Agents
  • Someone posing as any of these individuals
  • Any person (other than a covered dependent) who uses your ID card information to obtain medical care or to try to obtain reimbursement for health care services you did not receive

What are the warning signs?
Check your Explanation of Benefits (EOB) for items or services that:

  • you didn’t receive
  • are different than those you received
  • are unnecessary, inappropriate, or of questionable medical benefit

Examples of provider health care fraud include:

  • Billing for services not actually provided.
  • Filing claims for services or medications not received.
  • Falsifying a diagnosis or procedure to justify tests, surgeries or other procedures that are not medically necessary.
  • Unbundling services and billing all services separately when they should be included into one procedure.
  • Misrepresenting procedures provided to obtain payment for services that are not covered, such as cosmetic surgery.
  • Upcoding and billing for a more costly service than what was actually provided.

Examples of consumer health care fraud include:

  • Filing claims for services or medications not received.
  • Using someone else’s coverage or insurance card.
  • Forging or altering bills or receipts.

How can I help to prevent health care fraud?

  • Read your Explanation of Benefits (EOB) and verify you received all of the services listed.
  • Safeguard your health insurance card the same way you would your credit card.
  • Ask your doctor to explain the reason for services.
  • Question “free” medical services – especially when they ask for your insurance information.

Resources

Report fraud or abuse

Use our online form to report suspected health care fraud or abuse. This form is completely confidential. You will need to provide:

  • Your complete contact information, including your health insurance identification number.
  • The name and address of the complaint subject.
  • An explanation of what you suspect is fraud or abuse.

For questions about fraud awareness or to discuss a potential case of abuse, please contact us at (877) 249-2176.