Health Care Fraud
Health care fraud is committed when false or misleading information is submitted to improperly maximize the amount of health care benefits paid. It is a crime. Fraud comes in many forms — from contriving complex billing schemes to using someone else’s ID card to obtain medical services.
The cost of fraud affects everyone. The U.S. General Accounting Office estimates that health care fraud costs consumers approximately $35 to $60 billion dollars annually. For employers, fraud increases the cost of providing benefits and the overall cost of doing business. This translates into higher premiums and out-of-pocket costs for employees.
Examples of Fraud
Most health care providers and consumers are honest and ethical; only a small portion engages in fraudulent acts. The U.S. Chamber of Commerce estimates that 3 percent to 10 percent of health care cost is attributed to fraud annually.
What Constitutes Fraud?
- billing for services not provided;
- falsifying medical diagnoses or procedures to maximize payments;
- misrepresentation of dates, descriptions of services, or identities of plan members or providers;
- billing for a costlier service than the one that was provided or billing for duplicate services;
- accepting bribes for patient referrals;
- billing for non-covered services as covered items (for example, cosmetic surgery);
- providing false employer group and/or group membership information;
- prescription fraud;
- rent-a-patient fraud schemes.
What to look for:
- mistakes on your Explanation of Benefits (EOB) such as payments made for services that were not performed or names and dates that don’t agree with your records;
- individuals using an expired health insurance ID card;
- an individual who “lends” his or her card to someone who is not entitled to use it;
- drug diversion, over-utilization, or substitution of brand name drugs for generic.
If you suspect health care fraud or abuse, we urge you to report it. All reports are confidential.
You have three options for submitting your report:
- Submit a Fraud & Abuse Tip Referral Form electronically;
- call the confidential anti-fraud hotline at 1-215-640-7470 or toll-free at 1-866-282-2707;
- mail your report. Write a description of your complaint, enclose copies of any supporting documentation, and mail it to:
- Independence Administrators
Corporate & Financial Investigations Department
1901 Market Street, 15th Floor
Philadelphia, PA 19103
Health care fraud is a violation of state and/or federal law. Under federal law it is a felony offense (18 USC 1347), punishable by a fine of up to $250,000, and/or up to 10 years’ imprisonment. If the violation results in serious bodily injury, up to a 20-year prison term is possible.