The U.S. Chamber of Commerce estimates that three to ten percent of health care costs are attributed to fraud annually.
What constitutes fraud?
- billing for services not provided;
- falsifying medical diagnoses or procedures to maximize payments;
- misrepresentation of dates, descriptions of services, or identities of subscribers/providers;
- billing for a more costly service than the one that was provided or for duplicate services;
- accepting bribes for patient referrals;
- billing for non-covered services (e.g., cosmetic) as covered items;
- providing false employer group and/or group membership information;
- prescription fraud, to include Medicare Part D drugs.
What to look for:
- individuals using an expired health insurance ID card;
- an individual who “loans” his/her card to someone who is not entitled to use it;
- mistakes on your Explanation of Benefits (EOB), such as payments made for services that were not performed or names and dates that don’t agree with your records;
- drug diversion, over utilization, or substitution of brand for generic.
