Common Types of Fraud

As health care consumers, we all eventually pay the price for fraud.  While the majority of consumers are honest, there is a small percentage of people who take advantage of the system. According to the National Health Care Anti-Fraud Association an estimated $100 million is lost daily due to health care fraud.

Provider Potential Fraud Issues:

• Billing for services not rendered
• Billing for "free services"
• Inaccurate reporting of diagnosis or procedures to maximize payments
• Misrepresenting actual services or dates of service
• Billing non-covered services as covered services
• Eligible providers billing for the services provided by a non-eligible provider
• Accepting or offering kickbacks or bribes

Members:

• Loaning out a member identification card
• Enrolling an ineligible dependent for coverage or not removing dependants when they are no longer eligible
• Altering the amount charged, date of service, or quantity amounts on a claim form or prescription
• Creating claims
• "Doctor shopping" including excessive trips to the emergency room in order to obtain controlled substances

Non-Members

Using a stolen member identification card for medical services and/or prescriptions.