Fraud and abuse
Health care fraud and abuse steals billions of dollars every year from all of us:
- The Centers of Medicare and Medicaid Services estimates that $97 billion a year is lost to fraud through federal health programs, mainly Medicare and Medicaid.
- The National Health Care Anti-Fraud Association estimates as much as ten cents of every health care dollar is lost to fraud and abuse—that's more than $170 billion.
Your premium dollars and even your benefit coverage are a magnet for health care fraud and abuse. Phony billing scams increase costs for everyone, and medical identity theft can result in loss of your benefits and add incorrect information to your medical records.
That's why it's important to learn more about health care fraud and abuse, and what all of us can do to fight it.
What is health care fraud and abuse?
Health care fraud occurs when someone intentionally misrepresents a fact on a health care claim for the purpose of receiving—or increasing—reimbursement from a health plan. Fraud also occurs when someone misrepresents the delivery of health care services or supplies.
Health care abuse occurs if an activity abuses the health care system but does not meet the legal definition of fraud. Examples include over-use of services, or changing procedure codes and "unbundling" of services usually delivered together, to increase reimbursement.
Frequently asked questions about fraud
My health plan member card was stolen. Should I report it to Regence?
If your member card is stolen, you should immediately report it to prevent payment of services to any unauthorized person.
I received an Explanation of Benefits for services I didn't receive. Is this fraud?
Possibly. Billing for services not rendered is one of the most common types of health care fraud committed by providers. However, it may be a simple mistake. Always report erroneous charges to us. Our Special Investigations Unit will thoroughly research the charges and determine whether it is fraud or just a simple billing error.
I'm newly divorced. Is it OK to keep my ex-husband on my coverage?
No. Once your divorce is final, the coverage terminates, usually at the end of the month when the decree was issued. The divorced spouse is then ineligible for dependent coverage. If he continues using your benefits, both of you could be prosecuted. Having any ineligible person (for example, over-age child) on your coverage will result in an overpayment (if claims have been made for that ineligible dependent) and can result in criminal prosecution.
My physician billed my health plan for an office visit when all I did was pick up a prescription. I never saw my physician. Can he charge for this?
No. This would be considered billing for services not provided and should be reported to us immediately.
I think my physician may be billing fraudulent charges. If I report this and you later confirm that no fraud was committed, will my provider know I reported him?
You are not required to identify yourself when reporting suspected fraud. You should never be afraid to report your physician for suspicions of fraudulent billing or inappropriate behavior. We take every complaint seriously and are committed to protecting your confidentiality. Remember, if the provider is filing fraudulent charges under your coverage, then he or she most likely is filing false charges under other patients' coverage as well.
What are the most common types of fraud?
The most common types are intentional misrepresentations, such as:
- Billing for services not provided
- Double billing
- Billing for services performed by non-licensed persons
- Inflated billings
- "Unbundling," or billing separately for component parts of a medical procedure
- "Upcoding," or billing for a higher level of service than what was performed
- Billing for services originally advertised as "free"
- Over-utilization of services
- Billing non-covered services as covered services
Other examples of fraud include:
- Waiving deductibles and copays (for example, "I'll take what the insurance pays" or "I'll just add a few services to cover the deductible")
- Prescribing, then offering to buy back powerful narcotics after the insurance has paid for the prescription
As a physician, if I believe one of my employees is diverting claims payment checks or falsifying claims in order to receive stolen monies, what should I do?
Conduct an audit of accounts receivable and accounts payable. Then, limit the ability of any one person to misappropriate the accounts receivable. Finally, notify us of any false payments or misappropriated checks for further investigation.
I am a health care provider. What should I do if another provider offers to refer patients to me (or asks me to refer patients to them) for certain financial incentives?
You should decline the offer and notify the local State Department of Insurance and/or the SIU of the insurance company.