Healthcare Fraud.
Healthcare Fraud and how it affects you.
• Healthcare fraud costs Americans an estimated $54 billion dollars annually.
• Healthcare fraud is committed by a multitude of individuals including medical providers, members as well as pharmacies.
• Healthcare fraud increases the cost of healthcare for everyone.
• Healthcare fraud jeopardizes the overall healthcare of consumers.
Common Types of Healthcare Fraud.
• Services Not Rendered.
•• Billing for services that were not rendered to the member.
• Misrepresentation of Services.
•• Billing for a covered service when an uncovered service was actually rendered.
• Medically Unnecessary Services.
•• Billing for services that are not necessary for the treatment of the member.
• Upcoding Services.
•• Billing for services that are more complex and at a higher reimbursement than the actual service provided.
• Unbundling Services.
•• Billing for services separately instead of billing the code that includes multiple services.
• Misrepresentation of Identity (member/provider).
•• Falsely receiving or billing for services under a covered member's identity.
• Doctor Shopping.
•• Receiving various narcotic medications from a multitude of physicians through deceit.
• Misrepresentation of Eligible Dependents.
•• Maintaining eligibility for or adding an individual who does not legally qualify for benefits under the Program.
What You Can do to Combat Healthcare Fraud?
• Protect your health benefits identification card as you do your credit card.
• Review your Explanation of Benefit (EOB) summary to ensure that the services billed were actually rendered.
• Be selective in sharing your health insurance information.
• Be cautious of free medical exams, co-payment/co-insurance waivers and advertisements stating "covered by insurance".
• Provide timely eligibility changes.
How do I report Suspected Healthcare Fraud?
Call the FEP Fraud Hotline @ 1.800.337.8440.
Or Write to:
United States Office of Personnel Management.
Office of Personnel Management.
Office of the Inspector General Fraud Hotline.
1900 E Street, NW.
Washington, DC 20005.
Or Contact Your Local Plan.
Written by Lisa Chase-Craig, Blue Cross and Blue Shield Association.