Understanding and Preventing Health Care Fraud, Waste, and Abuse

January 3, 2019

Fraud, waste, and abuse in the health care industry is a rapidly growing problem. As such, it is important for you to understand what each of these issues are and what you can do to prevent them from having a negative effect on your life. To begin with, let’s take a look at how each of these issues are defined:

• Fraud is when someone intentionally lies to a health plan, insurance company, Medicaid, or Medicare, to get money or receive coverage.
• Waste is when someone overuses health services carelessly.
• Abuse is when best medical practices are not followed, leading to expenses and treatments that are not needed.

Now that you understand how each of these issues are defined, let’s review some of the most common scams that are used in relation to health care fraud, waste, and abuse:

• Identity Theft: This is the fastest growing type of health care fraud. It can include having your information stolen and/or your identity use without consent.
• False Claims: Individuals submitting false claims who are not doctors and did not provide a service.
• Doctor Shopping: This is when a person visits multiple doctors to get many prescriptions for controlled substances.
• Kickbacks: People are paid to get procedures they do not need, or doctors pay other doctors for referrals.
• Misrepresenting Services: Doctors claim they did a costlier procedure than what really occurred.
• Phantom Billing: A real patient’s information is used to make up claims or increase the number of valid claims.
• Unbundling: This is billing for each stage of a procedure one by one, as if the doctor was doing more than one procedure.
• Upcoding: Billing for a service that costs more than the service that was actually provided to a patient.

Finally, let’s detail a few ways you can prevent these scams from happening to you:

• Review Your Explanation of Benefits (“EOBs”): This is the most important way you can protect yourself! Your EOBs are snapshots of your doctor’s visits. When you receive it in the mail or access it online, make sure the services listed on it match the services you actually received.
• Watch Out For “Free” Services Claims: If you get offered free medical exams or copay waivers, or you see advertisements that say, “covered by insurance,” be careful.
• Avoid Identity Theft: Do not leave your ID card exposed, and if it is lost or stolen, report it immediately.

If you think you may be a victim of fraud, you can contact Empire BlueCross BlueShield at (844) 416-6387, Express Scripts at (800) 939-2091, or ASO/SIDS at (800) 537-1238, for assistance.