Frequently Asked Questions

What does it mean to commit health or dental benefits fraud? Know the facts so you can recognize it, refuse it and report it. Find answers to your questions here.

What is health and dental benefits fraud?
Benefits fraud occurs when you intentionally submit false or misleading information to your insurance provider for the purpose of financial gain.
Who commits health and dental benefits fraud?
Benefits fraud can be committed by health or dental service providers, plan members or both.
What are the consequences of health and dental benefits fraud?
The consequences of benefits fraud can include loss or reduction of your benefits, loss of employment, a criminal record, fines and jail time.
How can you protect yourself from the consequences of health and dental benefits fraud?

Learning how to recognize benefits fraud is the first step toward preventing it. If you suspect your health or dental service provider or coworkers are encouraging you to submit a fraudulent claim, or something just doesn’t feel right, report it to your employer or insurance provider immediately. You can also report benefits fraud anonymously here: report benefits fraud.

What are some examples of health and dental benefits fraud?
  • Billing for services that never occurred
  • Health or dental service providers offering excessive cash incentives to attract new patients
  • Health or dental service providers falsifying medical conditions to provide an unnecessary treatment or service
  • Health or dental service providers and plan members conspiring to increase the amount of a claim to ensure full coverage so the plan member doesn’t have to pay the deductible
  • Claiming services different than those provided
  • Transferring unused benefits to others, such as using a dependent’s unused benefits to cover another’s health or dental expenses
     
What are some reasons why people commit health and dental benefits fraud?

People commit benefits fraud for a number of reasons, such as:
● Financial need
● Pressure from family, friends or colleagues who are committing benefits fraud
● A health or dental service provider suggested it and they don’t know it’s wrong
● They don’t believe it causes harm
● They don’t know or think about the consequences or how serious they can be
 

Could you go to jail for health and dental benefits fraud?

Yes. Fraud is a serious crime and depending on the severity of the case, jail time may be one of the consequences.

Could health and dental benefits fraud lead to a criminal record?
Yes. If you are convicted of benefits fraud, you will have a criminal record.
Could you lose your job due to health and dental benefits fraud?
Yes. Fraud is a serious crime that may result in the loss of your job.
How do you report health and dental benefits fraud?

You can report benefits fraud directly to your employer, or anonymously here

Can you report health and dental benefits fraud anonymously?

Yes. If you would like to report benefits fraud anonymously, you can do so here. 

How do people get caught committing health and dental benefits fraud?
Employers often review how their benefits plans are being used, and sometimes employ data analysts to detect suspicious activity. Insurance companies have elaborate systems and sophisticated technology in place to detect unusual patterns and can flag suspicious claims. Some also conduct random audits. Some investigations are started from tips from the public. Insurance companies can share the evidence from an investigation with your employer.
Can health and dental service providers commit benefits fraud?

Yes. Health and dental service providers can commit benefits fraud by:

  • Billing for services or treatments that never occurred

  •  Offering substandard medical products with large incentives like free gifts or cash, along with an inflated receipt

  •  Falsifying medical conditions to provide an unnecessary treatment or service.

  •  Conspiring with plan members to increase the amount of a claim to ensure full coverage so the plan member doesn’t have to pay the deductible

What is an explanation of benefits (EOB)?

An explanation ofbenefits, also referred to as an EOB, is a written form provided by an insurer detailing a plan member’s claim, and itemizing what is covered and what the plan member is responsible for paying according to their plan.