Healthcare Fraud, Waste, and Abuse
Healthcare fraud affects everyone. It impacts the quality of healthcare and results in higher costs to you the consumer, your employer, and taxpayers. Losses due to healthcare fraud, waste, and abuse cost our country billions of dollars per year. It can also result in patient harm, when services are performed that are medically unnecessary or are performed by unqualified providers, or when needed services are denied because benefits were exhausted due to fraudulent claims for services the patient never actually received.
What is Fraud, Waste, and Abuse?
Fraud is the intentional misrepresentation or deception to receive an unauthorized benefit. In other words, it is when someone lies to get money or other benefits to which they are not entitled.
Waste is the overutilization of services or misuse of resources that result in unnecessary costs.
Abuse is defined as provider practices that are not consistent with sound medical or fiscal practices, and result in unnecessary costs.
Examples of healthcare fraud, waste, and abuse include:
- Services Not Rendered: Claims submitted for services or items that were not performed or delivered.
- Upcoding: Billing for a higher level of service than that which was rendered.
- Drug Diversion: When prescription medicines are obtained or used illegally.
- Medically Unnecessary Services: Billing for services that are not reasonable and necessary for diagnosis and treatment.
- Falsifying Records: Performing a non-covered service but documenting it as a covered service in order to receive payment.
- Unbundling: Billing individually for a group of services that are “bundled” or covered together under one comprehensive service code.
What Can You Do to Help Fight Fraud, Waste, and Abuse?
Review your Explanation of Benefits (EOB). Make sure the services listed on the EOB were actually received. If they were not, contact us at the phone number, email address, or website listed below.
Protect your medical identification number. Make sure you only provide your health insurance information to legitimate providers who have provided, or are about to provide, you with medical services.
If you suspect fraud, waste, or abuse has occurred, contact us.
How to Report Fraud, Waste, or Abuse:
You can report online here: Healthcare Fraud Form. You do not have to include your contact information if you wish to remain anonymous.
You can report by telephone on our FWA/Compliance Hotline at 1.877.296.7283.
You can contact us by email at SIU@healthplan.org.
