Fraud and healthcare

Health care fraud is a serious issue and it can affect everyone, including you.

Results of health care fraud may be inaccurate medical records, lost benefits, increased premiums and medical expenses.

What is health care fraud?

Health care fraud is the intentional misrepresentation of information to gain undeserved payment for a claim.

What is abuse?

Abuse involves a questionable practice, which is inconsistent with accepted medical or business policies. Although it is not an intentional misrepresentation, it may result in unnecessary costs.

Who can commit fraud or abuse?

• Members and patients
• Health care providers, including doctors, hospitals, clinics, labs, etc.
• Employer groups
• Agents
• Someone posing as any of these individuals
• Any person (other than a covered dependent) who uses your ID card information to obtain medical care or to try to obtain reimbursement for health care services you did not receive

Examples of provider health care fraud

• Billing for services not actually provided.
• Filing claims for services or medications not received.
• Falsifying a diagnosis or procedure to justify tests, surgeries or other procedures that are not medically necessary.
• Unbundling services and billing all services separately when they should be included into one procedure.
• Misrepresenting procedures provided to obtain payment for services that are not covered, such as cosmetic surgery.
• Coding and billing for a more costly service than what was actually provided.

Examples of consumer health care fraud include

• Filing claims for services or medications not received.
• Using someone else’s coverage or insurance card.
• Forging or altering bills or receipts.

How can I help to prevent health care fraud?

• Read your Explanation of Benefits (EOB) and verify you received all of the services listed.
• Safeguard your health insurance card the same way you would your credit card.
• Ask your doctor to explain the reason for services.
• Question “free” medical services – especially when they ask for your insurance information.

Beware of potential scams

Protecting yourself from identity theft during Open Enrollment
Identity theft occurs when someone obtains your personal information and uses it to bill for medical supplies and services. It is always important to protect your Medicare and health plan insurance numbers, but be especially careful during Open Enrollment. Never give out your Social Security, Medicare or health plan insurance numbers to someone you don’t know. And of course, carefully review your plan statement to ensure all the information is correct.
Besides those precautions, please be wary if any of the following occur:

• Someone says that you are eligible for a refund based on last year’s premium or because you have reached your prescription drug plan “donut hole” and they need your Medicare or health plan insurance number to issue the refund to you.
• A company offers you free medical supplies, gift cards or other offers if you provide your Medicare or health plan insurance number.

To report suspected identity theft or fraud, call (877) 249-2176 or email us at special.investigation@prevea360.com.

Beware of “Free” Services

Be wary of persons calling you and offering “free” gift cards in exchange for your insurance or credit card information.

To protect yourself never give your personal information to someone you don’t know. If you receive a telephone call or voice message, hang up and do not press any keys or numbers when prompted even if it is to be removed from their list.  

If you suspect services have been submitted to your Prevea360 Health Plan account that you did not receive, contact us on our Fraud Hotline (877) 249-2176 or email us at special.investigation@prevea360.com.

Resources

• Coalition Against Insurance Fraud
• National Health Care Anti-Fraud Association
• State of Wisconsin Department of Safety and Professional Services (DSPS)
• Health and Human Services Office of Inspector General

Report fraud or abuse

Use our online form to report suspected health care fraud or abuse. This form is completely confidential and you may remain anonymous. Important information you will need to provide to allow the issue to be reviewed is:

• The name and address of the complaint subject
• An explanation of what you suspect is fraud or abuse
• Your complete contact information, including your health insurance identification number, unless you wish to remain anonymous

If you have questions about fraud awareness or to discuss a potential case of abuse, contact us at (877) 249-2176 or via email special.investigation@Prevea360.com..