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 can affect you by resulting in higher copayments and premiums. This means more money out of your pocket. Fraud can also impact the quality of care you receive, falsify your medical history and/or deprive you of some of your health benefits.

Studies show that about $68 billion a year is lost to health care fraud in the United States. In order to control costs and protect members, insurance companies, including Denver Health Medical Plan (DHMP), investigate all allegations of fraud or abuse.

Who Commits Fraud?

Fraud can be committed by both members and providers.

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
  • 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 Fight Fraud:

DHMP fights fraud and helps protect the dollars our members spend on health care through a dedicated team called the Special Investigations Unit (SIU). The SIU resides within the Denver Health Enterprise Compliance Services Department. The SIU uses the latest fraud detection software, audits, data analysis, hotline and other tools to identify and investigate improper, deceptive and potentially fraudulent billing.

Employees are trained in how to identify fraud and abuse and how to refer concerns to the SIU.
Audits are conducted to investigate allegations of fraud or high-risk topics, such as medical necessity and appropriateness of services, proper billing, eligibility for coverage and more.
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 or abuse.

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.
601 Broadway, Mail Code 7776
Denver, Colorado 80204

By email: compliancedhmp@dhha.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) and other communications from DHMP when you receive them in the mail. An 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.