Fraud, Waste and Abuse

What Is Health Care Fraud, Waste and Abuse?

Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program.

Waste is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Waste is generally not considered to be caused by criminally negligent actions, but rather the misuse of resources.

Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the Medicare program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment, and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.

Intent is the key distinction between fraud and abuse. An allegation of waste and abuse can escalate into a fraud investigation if a pattern of intent is determined.

How Does Fraud, Waste and Abuse Affect You?

Fraud, waste and abuse diverts significant resources away from necessary health care services, which results in paying higher copayments and premiums, and other costs. Fraud can also impact the quality of care you receive and even deprive you of some of your health benefits.

Studies show that billions of dollars are lost each year to health care fraud in the United States. Laws are in place to prevent health care fraud and abuse, and to punish those who commit this crime. Insurance companies such as BayCarePlus also investigate and try to prevent fraud.

Who Can Commit Fraud?

There are many types of health care fraud, which can be committed by individuals, medical providers, employers and others. The primary goal of fraud is to profit financially, or to obtain medical care without valid insurance.

Examples of Individual Fraud

• Using someone else’s ID card or loaning your ID card to someone not entitled to use it
• Providing false statements on an enrollment application, such as adding spouse or dependent information to obtain coverage, or concealing information about past medical history or preexisting conditions
• Visiting different doctors to obtain multiple prescriptions
• Exaggerating a claim
• Providing false information in order to receive medical coverage or services
• Failing to report other insurance, or to disclose claims that were a result of a work-related injury

Examples of Provider Fraud

• Billing for services that weren’t provided to the patient
• Providing services that aren’t medically necessary for the purpose of maximizing reimbursement
• “Upcoding” – billing for a more costly service than was actually provided
• “Unbundling” – billing each step of a test or procedure as if it were separate, instead of billing the test or procedure as a whole
• Submitting claims with false diagnoses to justify tests, surgeries or other procedures that aren’t medically necessary
• Waiving member copays or deductibles
• Accepting kickbacks for member referrals

How We’re Fighting Fraud

BayCarePlus fights fraud and helps protect the monies our members spend on health care through a dedicated department called the Special Investigations Unit (SIU). The SIU uses the latest fraud-detection software, fraud hotlines, audits, data analysis and other tools to identify and investigate improper, deceptive and fraudulent billing.

Identify – BayCarePlus employees are trained in how to identify possible fraud and abuse and will refer these issues to the SIU for investigation.

Detect – SIU staff perform investigations and conduct activities to verify medical necessity, appropriateness of services, proper billing, eligibility for coverage and more.

Prevent – Claim management tools assist with the identification of inconsistent and illogical relationships among claims data. State-of-the-art data mining tools are used to identify providers and members who may be involved in fraud.

How You Can Help

• Ask your doctor questions and make sure you know and understand the procedures and services performed.
• Be cautious when using websites – don’t enter personal information such as Social Security number, Medicare number, credit card number, etc., unless you’re sure it’s secure.
• Refuse to accept any packages received from an unknown pharmacy or other source.
• Review your Explanation of Benefits (EOB) when you receive it in the mail. Check to be sure you received the services listed. Are the dates correct? Are there charges that seem wrong to you?
• Report any suspicious activity or questionable services:
  Call our toll-free Compliance Hotline at (833) 490-0002 (TTY: 711). This number is available 24 hours a day, seven days a week. You may leave your name and telephone number or choose to remain anonymous.