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What you should know about health care fraud, waste & abuse

Help keep yourself and your loved ones safe

Health care fraud, waste and abuse affects everyone in the U.S.1 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. Abuse happens when best medical practices aren’t followed, leading to expenses and treatments that aren’t needed. And waste is when someone overuses health services carelessly.

Why it matters

When dishonest members or health care professionals engage in health care 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.

Puts a big dent in your wallet

The huge monetary losses increase the cost of your doctor visits, copays and monthly payments. The FBI estimates that health care fraud is responsible for 3% to 10% of all health care costs. That’s about $75 billion to $250 billion total per year.2 Ouch.

Prevents you from getting security clearances

Many jobs require a government security clearance, and those are issued to honest and trustworthy people whose loyalty to the U.S. can be proven.3 If you’ve been a victim of health care fraud, waste and abuse and never resolved the issue, you won’t be able to get the clearances because of your compromised health records.

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 health care professionals may put your health at risk for the sake of their own benefit and suggest services or procedures you don’t really need.

Makes you vulnerable to identity theft

You’re familiar with this one when it comes to credit cards. But medical identity theft is also a big problem. Not only does it cost you time and money to resolve the issue, 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.

The huge monetary losses increase the cost of your doctor visits, copays and monthly payments. The FBI estimates that health care fraud is responsible for 3% to 10% of all health care costs. That’s about $75 billion to $250 billion total per year.2 Ouch.

Many jobs require a government security clearance, and those are issued to honest and trustworthy people whose loyalty to the U.S. can be proven.3 If you’ve been a victim of health care fraud, waste and abuse and never resolved the issue, you won’t be able to get the clearances because of your compromised health records.

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 health care professionals may put your health at risk for the sake of their own benefit and suggest services or procedures you don’t really need.

You’re familiar with this one when it comes to credit cards. But medical identity theft is also a big problem. Not only does it cost you time and money to resolve the issue, 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.

See examples

Health care fraud, waste and abuse can take many forms, which makes it hard to spot. Here’s a breakdown of the most common types. Just select an icon to learn more.

Spotting scams

Tackling health care fraud, waste and abuse takes team work. Here you’ll see how we can partner with you and combat it together.

Fighting fraud, waste and abuse

Our main priority is to keep you safe. So we keep a watchful eye on fraud, waste and abuse in all its forms. These are some of the ways our investigative team fights scams:

  • 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 health care companies to track suspicious activity
  • Partnering with law enforcement to investigate potential fraud
  • Training all our employees to spot unusual claims

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 medical exams or copay waivers, or you see ads that say “covered by insurance,” be careful.
Take a look at your bill. Confirm that your insurance agent or broker sends your monthly payments to us.
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 about understanding your EOB, watch the video.

Report it

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

If you think you or one of your dependents has been a victim of health care fraud, waste and abuse, call the Member Services number on the back of your ID card to report it right away.

Sources:

  1. National Health Care Anti-Fraud Association website: The Challenge of Health Care 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 Health Care (accessed April 2017): healthaffairs.org.