What You Should Know About Health Care Fraud, Waste & Abuse
Why It Matters
Losses due to fraud can put a big dent in your walletSide 1 of 2 press enter for more information.
Costs you time and money and can compromise your safetySide 1 of 2 press enter for more information.
Fraudulent medical history increases your health risksSide 1 of 2 press enter for more information.
Past unresolved issues could become red flagsSide 1 of 2 press enter for more information.
Health Care Fraud, Waste and Abuse Examples
Falsifying Records or Claims
Doctors perform a procedure that isn’t covered by your health plan, so they bill us for a different service that’s covered by your plan. For example, they perform a tummy tuck but bill us for a hernia repair.
Health care professionals aren’t the only ones capable of abusing the system. In this case, a member decides to visit many doctors, pharmacies or emergency rooms to get multiple prescriptions for the same medicine.
Using Brand-Name Drugs
A doctor prescribes a brand-name drug when there’s a lower-cost generic option that works exactly the same way.
Say you’re not feeling well and you head to the doctor’s office. When you get there, only a nurse is available to see you. Upcoding happens when your doctor’s office lies and bills the insurance company as if you saw the doctor, which is a more expensive service.
This one’s interesting because the services are covered, but they’re billed separately so the practice can make more money. For example, a doctor bills the insurance company for several different tests as if they were done separately when you really just had one comprehensive test done.
Poor Care Coordination
Sometimes, when health care professionals don’t follow best practices, you end up back at the hospital. For example, if they don’t share your medical information with each other and work together to decide what’s best for you, you could get readmitted to the hospital due to complications that could have been prevented.4
Some dishonest health insurance agents or brokers may take advantage of you and pocket the money they’re supposed to be sending the insurance company for your monthly payments.
Billing for Services You Never Had
Sometimes when you visit the doctor, not much happens. That’s normally a good thing, but some doctors see this as an opportunity to bill the insurance company for services that were never performed on you.
If a doctor ever offers you something if you'll get a test or procedure that you don’t actually need, be careful. It’s a way of lying, and then billing us for the service and putting your health at risk.
Tackling health care 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 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?
- 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