Examples of Fraud
The U.S. Chamber of Commerce estimates that each year three to ten percent of health care costs are attributable to fraud.
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;
- billing for duplicate services;
- accepting bribes for patient referrals;
- billing 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 or her health insurance ID 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.