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.