Anti-Fraud and Financial Investigations
Most health care providers and consumers are honest and ethical; only a small portion engage in fraudulent acts. The U.S. Chamber of Commerce estimates that three to ten percent of health care cost is attributed to fraud, annually.
What Constitutes Fraud?
Fraud includes:
- billing for services not provided;
- falsifying medical diagnoses or procedures to maximize payments;
- misrepresentation of dates, descriptions of services, or identities of subscribers/providers;
- billing for a more costly service than the one that was provided or billing for duplicate services;
- accepting bribes for patient referrals;
- billing for non-covered services as covered items (e.g., cosmetic);
- providing false employer group and/or group membership information;
- rent-a-patient fraud schemes.
What to look for:
- individuals using an expired health insurance ID card;
- an individual who “loans” his/her card to someone who is not entitled to use it;
- mistakes on your Explanation of Benefits (EOB), such as payments made for services that were not performed or names and dates that don’t agree with your records.
Health care fraud is a violation of state and/or federal law. Under federal law it is a felony offense (18 USC 1347), punishable by a fine of up to $250,000 and/or up to ten years’ imprisonment. If the violation results in serious bodily injury, up to a 20-year prison term is possible.
