What is Health Care Fraud?

Health Care Fraud is recognized as any intentional misrepresentation of a significant fact submitted on, or in support of, a healthcare claim, or application for healthcare coverage, for the purpose of obtaining something, to which you, or someone else, is not entitled. The National Health-Care Anti-Fraud Association (NHCAA) conservatively estimates that $68 billion of annual health care spending is lost to health care fraud. This leads to financial losses across the board, from higher premiums and out-of-pocket expenses for consumers, as well as reduced benefits and coverage. The issue is growing exponentially as health care fraud becomes more and more complex. Here at ADVANTAGE we realize the urgency in providing information on the avoidance of health care fraud so to prevent financial stress for the consumer.

Examples of Health Care Fraud

Provider Fraud

• Phantom-Billing - Billing for services not actually performed
• Upcoding - Billing for a more costly service than the one actually performed
• Unbundling - Billing each stage of a procedure as if it were a separate procedure
• Performing medically unnecessary services solely for the purpose of generating insurance payments
• Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary
• Misrepresenting procedures performed to obtain payment for non-covered services such as cosmetic surgery
• Accepting kickbacks for patient referrals
• Waiving patient co-pays or deductibles and over-billing the insurance carrier or benefit plan
• Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract
• Delivering healthcare services without a proper license
• Misuse of the Insurance Card allowing an unauthorized person to use your ID for medical services

Member Fraud

• Using someone else's coverage or insurance card
• Filing claims for services or medications not yet received
• Doctor shopping in order to get services that are not needed
• Forging or altering bills or receipts
• Adding someone to a policy that is not eligible for coverage
• Failing to remove someone from a policy when that person is no longer eligible

What you can do to Prevent Health Care Fraud

• Be Informed. Know about the health care services you receive, keep good records of your medical care, and closely review all medical bills you receive.
• Read your policy and benefits statements and any paperwork you receive from your insurance company. Make sure you actually received the treatments for which your insurance company was charged, and question suspicious expenses. Are the dates of service documented on the forms correct? Were the services identified and billed actually performed procedures?
• Protect your health insurance ID card like you would a credit card. In the wrong hands, a health insurance card is a license to steal. Do not give out policy numbers to door-to-door salespeople, telephone solicitors or over the internet. Take care in disclosing your insurance information and report it to your insurance company if you lose your insurance card.
• Report Fraud. Call your insurance company immediately if you suspect you may be a victim of health insurance fraud. Many insurers now offer the opportunity to report suspected fraud online through their website.
• Beware of "Free" offers. Offers of free health services, tests or treatments are often fraud schemes designed to bill you and your insurance company illegally for treatments you never receive.

How to Report Suspected Health Care Fraud

In response to any suspicious health care fraud one may report any and all cases to the ADVANTAGE help line.

ADVANTAGE Help Line: Please call our confidential Health Care Fraud Hotline at 1-888-333-9576.