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What is Health Care Fraud, Waste and Abuse?
Fraud is defined as an intentional deception, false statement or misrepresentation made by a person with the knowledge that the deception could result in unauthorized benefit to oneself or another person. It includes any act that constitutes fraud under applicable federal or state law.
Waste is defined as the overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to Denver Health Medical Plan (DHMP), including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.
Abuse is defined as practices that are inconsistent with professional standards of care, medical necessity or sound fiscal, business or medical practices. Intent is the key distinction between fraud and abuse. An allegation of abuse can escalate into a fraud investigation if a pattern of intent is determined.
Understanding Fraud, Waste and Abuse
Health care fraud, waste and abuse increases health disparities by targeting the medically underserved and vulnerable individuals. In addition, fraud, waste and abuse negatively impacts quality of care.
There is a direct correlation between fraud, waste and abuse and substandard quality of care, medically unnecessary care, and medical care that results in injury.
Fraud can be committed by anyone, including members and providers.
- 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 spouse or dependent information, to obtain coverage
- Failing to report other insurance or to disclose claims that were a result of a work-related injury
- Billing for services that were not rendered
- Providing services that are not 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)
- Kickback (an exchange of money or anything else of value in order to influence a healthcare provider or a physician to make decisions that may financially benefit the party offering the incentive)
DHMP fights fraud, waste and abuse by protecting the dollars our members spend on health care through a dedicated team within the Payment Integrity Department (PI), called the Special Investigations Unit (SIU). The SIU uses the latest fraud detection software, audits, data analysis, referrals and other tools to identify and investigate errant, deceptive and/or potentially fraudulent reimbursement.
- Identify
The SIU team members are trained in how to identify, detect and/or prevent fraud, waste and abuse. In addition, the SIU team trains DHMP staff on various fraud, waste and abuse concerns and instructs them on how to refer any matters they deem appropriate to the SIU.
- Investigate
Audits are conducted to investigate allegations of fraud, waste and abuse. Audits focus on medical necessity, proper billing, unbundling, upcoding and kickbacks.
- Prevent
Claim processing tools assist with the identification of inconsistent and illogical relationships in claims data. State of the art data mining tools are used to identify providers and members who may be involved in fraud, waste and abuse.
- Report
By telephone
Our toll-free hotline, 1-800-273-8452, also called the Values Line, makes it easy for anyone to report suspected fraud and abuse. This number is available 24 hours a day, 7 days a week. You may give your name and number or choose to remain anonymous.
In writing
Denver Health Enterprise Compliance Services
ATTN: Compliance/SIU Dept.
770 Bannock St., MC 6000
Denver, Colorado 80204
By email
payment_integrity@dhha.org
You Can Help Fight Fraud, Waste and Abuse, Too!
One way you can help fight fraud is to review your Explanation of Benefits (EOBs) and other communications from DHMP when you receive them in the mail or via email.
An EOB is your notification that DHMP received a bill for services performed under your benefit plan. Check to ensure you received the services listed. Are the dates correct? Is the provider correct? Is the member listed correct? Are there charges that seem wrong to you?
Report any suspicious activity or questionable services to our Values Line at 1-800-273-8452. All calls and information received are handled confidentially.