Fraud and Abuse

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Health Care Fraud Costs You Money

Did you know?
Each year, health insurance fraud costs Americans more than all of the bank robberies and car thefts combined. Ultimately, the cost of fraud is passed on to each of us through higher medical costs, higher co-payments and higher insurance premiums. 
How to Report Suspected Fraud
To report suspected fraud, please call us at 1-800-IC-FRAUD (1-800-423-7283) or e-mail the Fraud Department at icfraud@empireblue.com.  
You are the best defense in fighting health care fraud. Choose a topic below to learn more. 
What is fraud?
What can I do to help?
What are you doing to fight fraud?
How can I learn more?
 
What is Fraud?
Fraud is when someone knowingly and willfully lies in order to get benefits or money. It happens when a claim includes intentional misrepresentation of services, supplies or prescriptions.  
The overwhelming majority of consumers are honest, and nearly all health care professionals truly have their patients’ best interest at heart. But for those who are dishonest, a little insider knowledge and the tool of technology can allow them to wreak havoc on the system. Some common schemes include:  

Billing for services or supplies that were not provided

Altering claim forms to get a higher payment

Billing non-covered services as covered services

Misrepresenting a patient's diagnosis to justify services or equipment furnished

Billing for duplicate services on separate claims

Billing for each stage of a procedure separately, as if the provider was performing multiple procedures

Enrolling an ineligible dependent or ineligible member-group

Billing for a higher level of service than was actually performed

Dispensing generic drugs but charging for brand name drugs; or providing less medication than was actually prescribed.

 
What can I do to help?
Fraud hurts you, your employer, your coworkers and your community. But you can protect yourself by being aware and watching out for suspicious situations. Here are some tips to guide you:  

Be cautious of free medical exams, co-payment waivers or advertisements stating “covered by insurance.” If the services are truly free, your insurance company should not be billed. Also, advertisements may be for non-covered services billed as covered services. Be sure to check with your insurance plan to be sure."

Think of your health insurance ID card as one of your credit cards. If it is lost or stolen, it can be used to gain access to drugs and services that you may be charged for. Report a lost or stolen ID card immediately.

Closely examine the Explanation of Benefits (EOB) you receive from your health insurer to verify the service billed was the service received. If there is a question or discrepancy, contact your health insurer immediately.

If you suspect fraud, please contact our Fraud Hotline at 1-800-IC-FRAUD (1-800-423-7283), e-mail the Fraud Department at icfraud@empireblue.com, or call the Customer Service number listed on the back of your ID card.

 
What are you doing to fight fraud?
We have two units dedicated to fighting fraud and abuse. The Special Investigations Unit is made up of former law enforcement personnel and experienced insurance claims specialists. The Clinical Investigations Unit is made up of doctors, nurses and data analysts. These units employ various methods to detect fraud. 

1. Using data mining tools that detect billing discrepancies and perform comparisons to other providers, as well as trending and pattern recognition.

2. Networking with other health insurers to compare notes on suspected perpetrators of fraud.

3. Working with law enforcement agencies to gather information.

4. Requiring all associates to go through fraud awareness training so they can identify indicators of fraud, and they can alert claim handlers to examine a claim more closely.

 
How can I learn more?
If you would like to learn more about health care fraud, please view our Fraud Awareness Web training course  
 

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