What You Should Know About Healthcare Fraud, Waste & Abuse

Help keep yourself and your loved ones safe

 

Healthcare fraud, waste and abuse affects everyone. So let’s make sure you know what it is, how to spot it and how to help us prevent it. What is it exactly? Well, fraud is when someone intentionally lies to a health insurance company, Medicaid or Medicare to get money. Waste is when someone overuses health services carelessly. And abuse happens when best medical practices aren’t followed, leading to expenses and treatments that aren’t needed.

 

How Can I Help?

 

You can help us spot scams and unusual activity tied to your health plan by understanding a few simple things:

Watch out for freebies

If you get offered free products or extra services, or you see ads that say “covered by insurance,” be careful.

Avoid identity theft

Don’t leave your ID card exposed, and report it if it’s lost or stolen.

 

Review your explanation of benefits (EOB)

Your EOB is a snapshot of your doctor’s visit. When you receive it in the mail or access it online, make sure the services listed on it match the services you actually received. To learn more, watch the Understanding Your EOB video.

Why It Matters

 

When healthcare professionals or any person engages in healthcare fraud, waste and abuse, it has an impact on you. Take a look at how this growing problem makes things harder for you and your loved ones by selecting the panels below.

Increased Costs

 

Losses due to fraud can put a big dent in your wallet

Healthcare fraud is a significant issue that has a considerable financial impact on the nation. According to the National Health Care Anti-Fraud Association (NHCAA), the financial losses due to healthcare fraud are estimated to be in the tens of billions of dollars each year. A conservative estimate puts the cost at about 3% of total healthcare expenditures, while other estimates range as high as 10% of annual healthcare spending. This could mean more than $300 billion annually, given the size of healthcare expenditure in the United States.

Identity Theft

 

Costs you time and money and can compromise your safety

Medical identity theft is a big problem. Not only does it cost you time and money, but if someone steals your information to get services or submit false claims, they can also compromise your safety. The thief could use up all your benefits, and then you wouldn’t be able to use them when you need care. Plus, a compromised health record could put you at risk for receiving treatments you don’t actually need or even keep you from getting life insurance in the future.

 

 

Health Risks

 

Fraudulent medical history increases your health risks

When you go to the doctor, your medical history, along with your current symptoms, help the doctor decide how to treat you. Sadly, some untrustworthy healthcare professionals may put your health at risk for the sake of their own benefit and order services or procedures you don’t really need.

 

Security Clearances

 

Past unresolved issues could become red flags

Many jobs require a government security clearance. If you’ve been a victim of healthcare fraud, waste and abuse and never resolved the issue, you may not be able to get a security clearance because of your compromised health records.

 

 

 

Healthcare Fraud, Waste and Abuse Examples

 

Healthcare fraud, waste and abuse can take many forms, which makes it hard to spot. Here’s a breakdown of the most common types. Please select a tab to learn more.

Spotting Scams

 

Tackling healthcare fraud, waste and abuse takes team work. Here you’ll see how we can partner and combat it together. Our main priority is to keep you safe. So we keep a watchful eye on fraud, waste and abuse in all its forms. Some of the ways our investigative team fights scams include:

 

 Looking carefully at claims and the information in them to spot red flags

 

 Keeping a close eye on doctors’ billing patterns for weird or suspicious charges

 

 Working with other healthcare companies to track suspicious activity

 

 Partnering with law enforcement to investigate potential fraud

 

 Training all our employees to spot unusual claims

Report It

 

You’re our best ally when it comes to preventing healthcare fraud, waste and abuse.

 

If you think you or one of your dependents has been a victim of healthcare fraud, waste or abuse, report it by calling the Member Services number on the back of your ID card or use the button below to fill out and submit a report online.

Contact Us

 

If you prefer to call or report anonymously, contact us at your state’s designated fraud hotline: 

 California:
1-888-231-5044

 

 Colorado: 
1-800-377-2227

 

 Connecticut: 
1-800-258-3258

 

 Georgia: 
1-800-831-8998

 Indiana:
1-877-283-1524

 

 Kentucky:
1-800-866-1186

 

 Maine: 
1-800-285-7424

 

 Missouri: 
1-888-451-1155

 Nevada: 
1-800-377-2227

 

 New Hampshire: 
1-800-203-3738

 

 New York:
1-800-423-7283

 

 Ohio:
1-800-848-9276

 Virginia: 
1-800-368-3580

 

 Wisconsin: 
1-800-544-3873

State not listed? 1-866-847-8247

 

Prefer to submit a confidential referral with our web form? Click here.

Sources:

1. National Healthcare Anti-Fraud Association website: The Challenge of Healthcare Fraud (accessed April 2017): nhcaa.org.

2. FBI archives website: Medicare Fraud Strike Force Charges 107 Individuals for Approximately $452 Million in False Billing (accessed April 2017): archives.fbi.gov/archives/neworleans/press-releases/2012/medicare-fraud-strike-force-charges-107-individuals-for-approximately-452-million-in-false-billing.

3. U.S. Department of State website: All About Security Clearances (accessed April 2017): state.gov/m/ds/clearances/c10978.htm.

4. HealthAffairs website: Reducing Waste in Healthcare (accessed April 2017): healthaffairs.org.