What is Fraud and Abuse?
Most providers and members are honest. Some are not. Fraud is when a provider or member knowingly gives false information that allows someone to get a benefit that is not allowed.
Billions of dollars are lost to health care fraud every year. That means money is paid for services that may never have been given. It could also mean that the service that was billed was not the one that was performed.
Examples of Fraud and Abuse
- Filing claims for services or medications not received
- Forging or altering bills or receipts
- Using someone else's ID or Medicaid card
- Billing for services not actually performed
- Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary
- Misrepresenting procedures performed to obtain payment for services that are not covered
- Waiving patient co-pays or deductibles
- Over-billing the insurance carrier, benefit plan, or member
- Billing for a more expensive service than what was actually rendered (Upcoding)
- Billing more than once for the same service (Double billing)
How to Report Fraud and Abuse
If you think fraud has taken place, call our 24-hour hotline. The number is 1-866-678-8355. It is private and you may leave a message without leaving your name. If you do leave your phone number, we will call you back to be sure our information is complete and accurate. You can also submit your concern online.