Health Care Fraud
The cost of health insurance fraud and abuse is estimated to be as much as $54 billion dollars each year. Efforts to identify and report fraud can save tens of millions of dollars. That’s why New York's health insurers, working with the New York Health Plan Association and the National Health Care Anti-Fraud Association, are joining together in a campaign to educate the public about fraud and its costs and to get consumers involved in the effort to reduce fraud.
What is Fraud?
Fraud is stealing, which is a crime, and it is a crime that affects everyone. When people commit health care fraud crimes, those actions contribute to rising costs of health care. Reducing health care fraud and abuse can help contain rising health care costs.
What is Considered Health Care Fraud?
The most common kind of fraud involves a false statement, misrepresentation or deliberate omission that is critical to the determination of benefits payable. The most common examples of health care fraud include, but are not limited to:
- Billing for services, procedures and/or supplies that were not provided.
- Ordering services that are unnecessary or unwarranted for the purpose of financial gain.
- The intentional misrepresentation of any of the following for purposes of manipulating the benefits payable:
- The nature of services, procedures and/or supplies provided.
- The dates on which the services and/or treatments were rendered.
- The medical record of service and/or treatment provided.
- The condition treated or diagnosis made.
- The charges or reimbursement for services, procedures, and/or supplies provided.
- The identity of the provider or the recipient of services, procedures and/or supplies.
By its nature, health care fraud revolves around the exploitation of patients and their health insurance information, and as such, it involves much more than financial loss. Fraud also involved the creation of false medical histories for the persons in whose names those false claims are filed. Depending on the nature of the fraud, some providers put patients at physical risk solely for the purpose of generating falsified claims.
What Can Consumers Do to Fight Health Care Fraud?
Consumers can take the following simple steps to help reduce fraud and abuse:
- Examine medical bills closely to verify services.
- Ask for explanations or clarification of any unusual or questionable services.
- Call your health insurance company to report any suspicious activities.
The following websites offer more information about fraud and what you can do to help prevent it:
New York Anti-Fraud Campaign
Since 2000, HPA and several member plans have partnered with the National Health Care Anti-Fraud Association to run a series of radio and print ads throughout New York State aimed at alerting the public to be aware of health care fraud in an effort to increase detection and prevention. These ads run twice yearly.
To get a PDF copy of the current Anti-Fraud ad, click HERE.