Help us fight health care fraud, waste and abuse

Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any healthcare benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any healthcare benefit program.

Waste is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Waste is generally not considered to be caused by criminally negligent actions, but rather the misuse of resources.

Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment, and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.

Fraud, waste, and abuse affects you by paying higher co-payments and premiums. This means more money out of your pocket. Fraud can also impact the quality of care you receive and falsify your medical history. Fraud can also deprive you of some of your health benefits.

Studies show that over 30 billion dollars a year is lost to health care fraud in the United States. In order to control costs, insurance companies have found it necessary to investigate fraud for the benefit of its members.

Fraud can be committed by members, providers, and employers.

• Using someone else’s ID card or loaning your ID card to someone not entitled to use it.
• Providing false statements on an enrollment application such as spouse or dependent information to obtain coverage or concealing information about past medical history/preexisting conditions.
• Failing to report other insurance or to disclose claims that were a result of a work-related injury.

• Billing for services that were not rendered.
• Providing services that are not medically necessary for the purpose of maximizing reimbursement.
• “Upcoding”-billing for a more costly service than was actually provided.
• “Unbundling”-billing each step of a test or procedure as if it were separate instead of billing the test or procedure as a whole.
• Submitting claims with false diagnoses to justify tests, surgeries, or other procedures that are not medically necessary.
• Waiving member co-pays or deductibles.
• Accepting kickbacks for member referrals.