What is Health Care Fraud 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.
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.
How does Fraud and Abuse affect you?
Fraud and abuse affects you by paying higher co-payments and premiums. This means more money out of your pocket. Fraud can also impact the quality of care you receive and falsify your medical history. Fraud can also deprive you of some of your health benefits.
Studies show that over 30 billion dollars a year is lost to health care fraud in the United States. In order to control costs, insurance companies have found it necessary to investigate fraud for the benefit of its members.
Who Commits Fraud?
Fraud can be committed by members, providers and employers.
Examples of Member 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 spouse or dependent information to obtain coverage or concealing information about past medical history/pre-existing conditions.
- 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 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.
How We are Fighting Fraud:
Denver Health Medical Plan, Inc. (DHMP) 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 resides within the Corporate Compliance Department. The SIU uses the latest fraud detection software, audits, data analysis, hotline, and other tools to identify and investigate improper, deceptive and fraudulent billing.
Employees are trained in how to identify fraud and abuse and how to refer cases to the SIU.
Audits are conducted to verify allegations of fraud, such as medical necessity and appropriateness of services, proper billing, eligibility for coverage and more.
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.
Via 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 leave your name and number or choose to remain anonymous.
Denver Health Medical Plan, Inc.
ATTN: Compliance SIU Dept.
938 Bannock Street, Mail Code 6000
Denver, Colorado 80204
Via email: firstname.lastname@example.org
All reports are investigated and involve the appropriate federal and state agencies when necessary.
You Can Help Fight Fraud Too!
One way you can help fight fraud is to review your Explanation of Benefits (EOBs) when you receive it in the mail. The EOB is your notification that DHMP received a bill for services performed under your benefit plan. 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 to our Values Line at 1-800-273-8452. All calls and information received are handled confidentially.