Health Care Fraud and Abuse Prevention
Health care fraud is a crime. Fraud is committed when a provider or patient intentionally submits false or misleading information to a health plan for use in determining the amount of health care benefits payable. As a Group Health member, there are steps you can take to prevent health care fraud and to report suspected fraud and abuse.
Examples of Health Care Fraud and Abuse
- Filing claims for services or medications not actually performed or obtained
- Billing for non-covered items using codes for covered items
- Billing for excessive or unnecessary medical services or supplies
- Billing for a more costly service than the one that was actually performed
- Altering billings or medical records
- Using unqualified personnel to perform treatments
- Accepting kickbacks for referring patients
- Waiving patient co-pays or deductibles
- Using someone else's coverage or insurance card
- Altering amounts charged on claim forms or prescription receipts
- Enrolling someone not eligible (for example, divorced spouse) for coverage on a health plan
- Including false information in an application for the purpose of obtaining coverage
What You Can Do to Prevent Fraud and Abuse
- Start by knowing your benefits and reading your Explanation of Benefits (EOB) statements and any paperwork received from Group Health Cooperative or your health care providers.
- Be wary of any "free" medical treatment, as these are usually scams.
- Protect your Group Health Cooperative member ID card as if it were your credit card.
How to Report Suspected Fraud and Abuse
If you suspect fraud and abuse, there are several reporting options available to you. All reports are confidential and can be anonymous, if you choose. You are not required to include your name, address, or other identifying information.
To report suspected fraud, contact our Fraud, Waste, and Abuse (FWA) Department:
- Send e-mail to FWA@ghc.org
- Call our confidential, toll-free hotline at 800-741-7817
- Call our FWA department at 206-988-2967
- Mail or fax a written description of your complaint, including copies of any supporting documentation to:
Group Health Cooperative
Fraud, Waste, and Abuse Department
12501 E. Marginal Way S., ASB 2
Seattle, WA 98168
The Impact of Health Care Fraud and Abuse
The impact of health care fraud and abuse is widespread, resulting in higher health insurance premiums. It is also recognized as a factor in the escalating cost of all health care.
The National Health Care Anti-Fraud Association estimates that of the nation's annual health care expenditure, at least 3 percent or $51 billion in 2003 is lost to fraud.
Other estimates by government and law enforcement agencies place the loss as high as 10 percent of our annual expenditure or $170 billion each year.
Source: National Health Care Anti-Fraud Association