You can help fight fraud, waste and abuse

The total health care spending amount is estimated to exceed $3 trillion annually in the United States. The FBI estimates as high as 10% of our annual health care expenditure is lost each year due to health care fraud. See the following links for additional info. (http://www.cdc.gov/nchs/fastats/health-expenditures.htm and http://www.fbi.gov/about-us/investigate/white_collar/health-care-fraud )
This results in higher costs for everyone:

·         Higher premiums and out of pocket expenses and reduced benefits

·         Customers experience higher cost of providing benefits to employees

·        
Providers experience higher operating costs

·        
Everyone suffers from a more rapid depletion of money from the Medicare trust fund and increased taxes

Common Healthcare Fraud, Waste and Abuse Schemes

Member

ü  Doctor Shopping

ü  Alteration of claims

ü  Lending the health plan card to another non-covered person 

Medical Identity Theft

 

ü  Stolen cards used to file fraudulent claims

ü  Stolen provider’s tax identification number used to file fraudulent claims

ü  The use of a stolen provider’s prescription pad

Provider

             

ü  Billing for services not rendered or rendered by a third party

ü  Adding modifiers to claims to acquire additional reimbursement

ü  Billing for non-covered services using an incorrect procedure or diagnosis code

Long Term Care

          

ü  Changing the member’s physical or mental status on the application or during the assessment evaluation to qualify for benefits.

ü  Provider or facility billing for more care and hours of services than are actually rendered.

ü  Facility billing for services of an individual who was not a client of the facility.

ü  Billing by an unlicensed or phantom facility.

Pharmacy

          

ü  Filling less than the prescribed quantity of a drug

ü  Pharmacy bills for brand name when generic drugs are dispensed

ü  Adulterated drugs through black market purchases

ü  Kickbacks, inducements, and other illegal remuneration

Accident and Disability

          

ü  Falsifying an injury or the extent of an injury in order to receive permanent or temporary disability benefits. 

ü  Continuing to submit claims for disability benefits where the insured is no longer disabled.

ü  Provider submits additional medical documentation misrepresenting the information to support false claims.

Consequences

There are severe consequences for committing fraud, waste, and abuse, the severity of which depends on the violation.

These can include:

• Civil money penalties

• Criminal conviction/fines

• Civil prosecution

• Imprisonment

• Loss of provider license

• Exclusion from federal health care programs

• Termination of provider contract