On its surface, healthcare fraud may seem like a victimless crime. But nothing could be further from the truth. Fraud costs you and insurance companies billions of dollars each year. It can also push up your premiums, reduce your benefits, and threaten the quality of care you receive.
What is healthcare fraud?
Healthcare fraud can take a variety of forms. Here are some examples:
- A doctor submits claims for services he did not provide.
- An employee conceals a spouse’s coverage to get reimbursement from two insurance companies.
- A dentist bills for a more expensive procedure than the one actually performed.
- A doctor waives the patient copayment or deductible.
- A doctor performs unnecessary tests or treatments.
While these may not seem to have an immediate impact on your wallet, we all pay for such activities in the long run.
What can you do?
Here are five things you can do to help:
- Be aware that healthcare fraud exists. Only a small percentage of providers practice fraud, but it adds up to billions of dollars every year—a bill we all end up paying.
- Become an educated consumer. Ask your doctor about recommended procedures and their costs.
- Don’t be a partner in fraud. Avoid special favors. For example, a doctor may offer to waive your copayment. A dentist may offer to double a claim amount to offset your copayment. Refuse such offers and let us know when you receive them.
- Help stop fraud by examining your medical bills and DMBA’s Explanation of Benefits. Make sure you are billed only for services that were performed. Compare the dates and services billed against your own records. Please review each Explanation of Benefits for accuracy.
- Call DMBA if you see discrepancies or if you suspect fraud. Honest mistakes do happen, but our DMBA claims experts will be able to look for patterns of past abuse.
- Get involved in fraud prevention and urge your friends and family to do the same. By keeping an eye out for healthcare fraud, we can avoid becoming innocent victims who ultimately pay the price.
Also, please ask about DMBA’s audit reimbursement benefit when you find mistakes on your claims and we’ll share the savings with you.
As you can see, people commit healthcare fraud when they intentionally submit, or cause someone else to submit, false or misleading information for use in determining benefits. Fraud could be committed by dishonest healthcare facilities, vendors, providers, or by participants of a health plan.
While the overwhelming majority of our participants and providers treat health claims fairly, we do encounter instances where individuals or providers attempt to gain through fraudulent acts. Such actions are illegal and are investigated and prosecuted by DMBA and law enforcement agencies. A person convicted of healthcare fraud may face imprisonment and substantial fines.
How does healthcare fraud affect you?
Why should you care about healthcare fraud? Because it costs money for you and your employer! Fraud can also impact the quality of care you receive. If a dishonest provider puts greed ahead of your care, he may ignore proper diagnosis and treatment and put you at risk solely to generate higher dollar claims.
How do you report healthcare fraud?
- Call DMBA at 801-578-5600 or 800-777-3622
- Write us at: Deseret Mutual Benefit Administrators
P.O. Box 45530
Salt Lake City, UT 84145-0530
- Send us a message through our secure message service.
Links to learn more about healthcare fraud
- The National Health Care Anti-Fraud Association (NHCAA): A cooperative effort of private-sector health insurers and public-sector law enforcement agencies to improve the prevention, detection, investigation, and prosecution of healthcare fraud. Visit NHCAA at www.nhcaa.org.
- The Centers for Medicare and Medicaid Services (CMS): A website containing information on Medicare fraud and how to prevent it. Visit CMS at www.hcfa.gov.
- AARP: A website providing information on the different types of healthcare fraud and the consequences of committing Medicare fraud. Visit AARP at www.aarp.org.