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.