Home | Fraud, Waste & Abuse

Help keep yourself and your loved ones safe

Health care fraud, waste and abuse affects everyone in the U.S.¹ So let’s make sure you know what it is, how to spot it and how to help us prevent it. What is it exactly? Well, fraud is when someone intentionally lies to a health insurance company, Medicaid or Medicare to get money. Waste is when someone overuses health services carelessly. And abuse happens when best medical practices aren’t followed, leading to expenses and treatments that aren’t needed.

Why It Matters

When health care professionals or any person engages in health care fraud, waste and abuse, it has an impact on you. Take a look at how this growing problem makes things harder for you and your loved ones by selecting the panels below.

Increased Costs

Losses due to fraud can put a big dent in your wallet

Identity Theft

Costs you time and money and can compromise your safety

Medical identity theft is a big problem. Not only does it cost you time and money, but if someone steals your information to get services or submit false claims, they can also compromise your safety. The thief could use up all your benefits, and then you wouldn’t be able to use them when you need care. Plus, a compromised health record could put you at risk for receiving treatments you don’t actually need or even keep you from getting life insurance in the future.

Health Risks

Fraudulent medical history increases your health risks

Security Clearances

Past unresolved issues could become red flags

Many jobs require a government security clearance, and those are issued to honest and trustworthy people whose loyalty to the U.S. can be proven.³ If you’ve been a victim of health care fraud, waste and abuse and never resolved the issue, you may not be able to get a security clearance because of your compromised health records.

Health Care Fraud, Waste and Abuse Examples

Health care fraud, waste and abuse can take many forms, which makes it hard to spot. Here’s a breakdown of the most common types. Please select a tab to learn more.

Falsifying Records or Claims

(Fraud)

Doctors perform a procedure that isn’t covered by your health plan, so they bill us for a different service that’s covered by your plan. For example, they perform a tummy tuck but bill us for a hernia repair.

Doctor Shopping

(Abuse)

Health care professionals aren’t the only ones capable of abusing the system. In this case, a member decides to visit many doctors, pharmacies or emergency rooms to get multiple prescriptions for the same medicine.

Using Brand-Name Drugs

(Waste)

A doctor prescribes a brand-name drug when there’s a lower-cost generic option that works exactly the same way.

Upcoding

(Fraud)

Say you’re not feeling well and you head to the doctor’s office. When you get there, only a nurse is available to see you. Upcoding happens when your doctor’s office lies and bills the insurance company as if you saw the doctor, which is a more expensive service.

Unbundling

(Abuse)

This one’s interesting because the services are covered, but they’re billed separately so the practice can make more money. For example, a doctor bills the insurance company for several different tests as if they were done separately when you really just had one comprehensive test done.

Poor Care Coordination

(Waste)

Sometimes, when health care professionals don’t follow best practices, you end up back at the hospital. For example, if they don’t share your medical information with each other and work together to decide what’s best for you, you could get readmitted to the hospital due to complications that could have been prevented.⁴

False Premiums

(Fraud)

Some dishonest health insurance agents or brokers may take advantage of you and pocket the money they’re supposed to be sending the insurance company for your monthly payments.

Billing for Services You Never Had

(Fraud)

Sometimes when you visit the doctor, not much happens. That’s normally a good thing, but some doctors see this as an opportunity to bill the insurance company for services that were never performed on you.

Kickbacks

(Fraud)

If a doctor ever offers you something if you'll get a test or procedure that you don’t actually need, be careful. It’s a way of lying, and then billing us for the service and putting your health at risk.

Spotting Scams

Tackling health care fraud, waste and abuse takes team work. Here you’ll see how we can partner and combat it together. Our main priority is to keep you safe. So we keep a watchful eye on fraud, waste and abuse in all its forms. Some of the ways our investigative team fights scams include:

Looking carefully at claims and the information in them to spot red flags
Keeping a close eye on doctors’ billing patterns for weird or suspicious charges
Working with other health care companies to track suspicious activity
Partnering with law enforcement to investigate potential fraud
Training all our employees to spot unusual claims

How Can I Help?

You can help us spot scams and unusual activity tied to your health plan by understanding a few simple things:

Watch out for freebies. If you get offered free products or extra services, or you see ads that say “covered by insurance,” be careful.

Avoid identity theft. Don’t leave your ID card exposed, and report it if it’s lost or stolen.

Take a look at your bill. Unless a service is covered by a specific government program, such as Medicaid, confirm your insurance agent or broker sends your monthly payments to us.

Review your explanation of benefits (EOB ). Your EOB is a snapshot of your doctor’s visit. When you receive it in the mail or access it online, make sure the services listed on it match the services you actually received. To learn more, watch the Understanding Your EOB video.

Report It

You’re our best ally when it comes to preventing health care fraud, waste and abuse.

If you think you or one of your dependents has been a victim of health care fraud, waste or abuse, report it by calling the Member Services number on the back of your ID card or use the button below to fill out and submit a report online.

Submit Report Online

Contact Us

If you prefer to call or report anonymously, contact us at your state’s designated fraud hotline:

California: 1-888-231-5044
Colorado: 1-800-377-2227
Connecticut: 1-800-258-3258
Georgia: 1-800-831-8998
Indiana: 1-877-283-1524
Kentucky: 1-800-866-1186
Maine: 1-800-285-7424

Missouri: 1-888-451-1155
Nevada: 1-800-377-2227
New Hampshire: 1-800-203-3738
New York: 1-800-423-7283
Ohio: 1-800-848-9276
Virginia: 1-800-368-3580
Wisconsin: 1-800-544-3873

State not listed? Call: 1-866-847-8247

Prefer to submit a confidential referral with our web form? Click here.

Sources:

^1. National Health Care Anti-Fraud Association website: The Challenge of Health Care Fraud (accessed April 2017): nhcaa.org.

^2. FBI archives website: Medicare Fraud Strike Force Charges 107 Individuals for Approximately $452 Million in False Billing (accessed April 2017): archives.fbi.gov/archives/neworleans/press-releases/2012/medicare-fraud-strike-force-charges-107-individuals-for-approximately-452-million-in-false-billing.

^3.U.S. Department of State website: All About Security Clearances (accessed April 2017): state.gov/m/ds/clearances/c10978.htm.

^4.HealthAffairs website: Reducing Waste in Health Care (accessed April 2017): healthaffairs.org.

What You Should Know About Health Care Fraud, Waste & Abuse

Help keep yourself and your loved ones safe

Why It Matters

Increased Costs

Identity Theft

Health Risks

Security Clearances

Health Care Fraud, Waste and Abuse Examples

Falsifying Records or Claims

Doctor Shopping

Using Brand-Name Drugs

Upcoding

Unbundling

Poor Care Coordination

False Premiums

Billing for Services You Never Had

Kickbacks

Falsifying Records or Claims

Doctor Shopping

Using Brand-Name Drugs

Upcoding

Unbundling

Poor Care Coordination

False Premiums

Billing for Services You Never Had

Kickbacks

Spotting Scams

How Can I Help?

Report It

Contact Us