Fighting health care fraud

Health care fraud, waste and abuse impacts all of us by raising health care costs, limiting health care resources and undermining confidence in our health care system.

Examples of health care fraud schemes include billing for:

• A medical service that was never performed.
• A more expensive level of medical service, medical supply or piece of equipment other than what was provided.
• Medical services that were provided but were not medically necessary.

We all need to work together to reduce health care fraud. That’s why we get help from our members, providers, employer groups, producers, as well as local, state and federal agencies and law enforcement. 

We also created a Special Investigations Department (SID) with staff from diverse backgrounds such as medical providers, professional coders, insurance industry experts and law enforcement. SID also has a Data Intelligence Unit to partner with SID investigators to identify and stop fraud, waste and abuse. When appropriate, SID refers fraud cases for criminal prosecution.

We also encourage our members to help fight health care fraud by:

• Understanding what their benefit plan covers
• Reviewing all Explanation of Benefits (EOB) statements. Members should make sure they had the medical exams, tests and treatments with the provider shown on the EOB
• Understanding what they are responsible to pay and knowing if their plan requires a deductible or copay
• Guarding their member insurance ID card, Social Security number and other personal information and calling as soon as possible if their insurance card or information is lost or stolen
• Never lending their member ID card to someone else
• Declining to give insurance information if medical services or equipment are offered as “free.
• Asking providers to explain why a service is necessary. If in doubt, get a second opinion from another doctor.