How to recognize and report Health Care Fraud
Sometimes fraud is easy to spot, like when someone steals your name and insurance information to get prescription drugs. Sometimes it’s not so easy, like a chiropractor who prescribes a back brace you don’t really need.
Signs of Fraud
Health care fraud is a felony that can endanger your health, your access to health insurance, and put your personal information at risk. Protect yourself and others by learning how to spot fraud.
Incorrect information on your Explanation of Benefit (EOB) statement can indicate fraud, especially if the date is wrong or you see a service listed you didn’t receive. It’s worth it to report a suspicious EOB. Otherwise you could be responsible for charges you shouldn’t have to pay.
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- Tip: Keep a personal log of your doctor visits, including the dates and services you received. That way you can compare it to your EOB.
- Medicare fraud. Unfortunately, people have found many illegal ways to take advantage of Medicare. Visit the Fraud and Abuse page of the Official U.S. Government Site for Medicare to learn about Medicare fraud. The more you know, the easier it is to recognize and avoid it.
- Guard your card. Loaning an insurance card or using an expired card to get medical care is fraud. So is keeping or putting someone on your contract who shouldn’t be there, like an ex-spouse.
- Don’t rent when you can buy. If you’re renting durable medical equipment, like a wheelchair or respirator, make sure you know the purchase price of the equipment. The rental company can’t keep billing you once your total rental payments exceed what it would cost to buy the equipment.
- When free isn’t. Health care providers who offer free services or waive your copay may not be a bargain. They may charge the insurance company more for other services to make up the difference, or add services you didn’t receive.
What is Waste?
Health care spending that can be eliminated without reducing the quality of care.
What is Abuse?
Improper behaviors that create unnecessary costs:
- Doctor Shopping
- Frequent visits to the ER for Medication
- Excessive in terms of frequency or duration
Fraud vs Waste and Abuse?
The following examples clarify the distinction between Fraud, Waste & Abuse:
- A member knowingly gives their insurance card to a friend/family member to use. This is fraud because the member is intentionally precipitating a misrepresentation.
- A member ‘doctor shops’ to obtain pain medications from several sources. This is abuse because the member is obtaining prescriptions without the guidance of their PCP in order to sustain an abusive habit.
- A member needs a return-to-work slip. They go to the emergency room to obtain one, instead of going to their PCP. This is waste because the member is taking advantage of the emergency room personnel for non-emergent care. This also results in higher costs to; hospital charges vs. PCP charges.
- The distinction between fraud and abuse is important, because fraud is a criminal act while waste and abuse is normally not. If waste and abuse occurs, the insurer may seek to recover monies that should not have been paid, but in most cases a crime has not been committed. In the case of fraud, a crime has occurred and a criminal prosecution may take place.