What is health care fraud?
It is an intentional (knowing and willful) act of deception, misrepresentation, or concealment in order to gain something of value. Health care fraud is a crime.
Some examples of provider health care fraud are:
- Billing for services not actually performed
- Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary
- Upcoding – billing for a more costly service than the one actually performed
- Unbundling – billing each stage of a procedure as if it were a separate procedure
- Accepting kickbacks for patient referrals
- Waiving patient co-pays or deductibles and over-billing the insurance carrier or benefit plan
- Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract
- Misrepresenting procedures performed to obtain payment for non-covered services, such as cosmetic surgery;
Some examples of consumer health care fraud are:
- Filing claims for services or medications not received
- Forging or altering bills or receipts
- Using someone else's coverage or insurance card
Help avoid and prevent health care fraud
Here are some easy ways you can protect against health care fraud, and keep health care costs down for everyone:
- Ask questions about the services you receive, such as: Why are they needed? What do they cost?
- Fill out, sign and date one claim form at a time.
- Be careful about disclosing your insurance information. Protect your HealthCare ID card. It represents your benefits.
- Compare your Health Plan’s Explanation of Benefits (EOB) and/or your medical bills with your records. Are the dates of service correct? Were the services actually performed?
- Report suspected fraud to eviCore healthcare's Compliance department.
eviCore healthcare is working to minimize health care fraud
Our Corporate Compliance team is responsible for minimizing eviCore healthcare’s risk to health care fraud. The compliance team partners with eviCore healthcare's Customer Service Claim department and others to help identify suspicious claims, stop payments to fraudulent providers and punish wrongdoers.
The compliance team also works with state and federal law enforcement and regulatory agencies and other insurance companies to detect, prevent and prosecute health care fraud. The compliance team includes trained professionals with expertise in investigations, health care, nursing, law enforcement and accounting.
How to Report Health Care Fraud