HOW TO RECOGNIZE HEALTH AND DENTAL BENEFITS FRAUD
Benefits fraud is not always easy to spot, especially when a trusted coworker, friend, family member or health or dental service provider suggests it. Look for these warning signs and alert your insurer if they occur:
- Feeling pressured by your health or dental service provider to get unnecessary products or procedures
- Being encouraged to claim products or services that are not eligible as a benefit under your plan as different products or services that are eligible
- Health or dental service providers who seem more concerned with the details of your insurance coverage than providing the right product or service
- Feeling encouraged to include incorrect or misleading information on a claim
- Being asked to sign a blank claim form (often completed later with misleading information)
- Health or dental service providers who use your plan membership information to charge for products and services you never received Being offered cash or other incentives in exchange for your policy information
HOW TO USE YOUR BENEFITS APPROPRIATELY
Understanding your benefits and how to use them appropriately can help you recognize and guard against potential fraud. Here’s how:
- Familiarize yourself with your benefits plan and the limits of your coverage
- Keep your personal benefits plan access information in a safe place and don’t lend your card to anyone
- Be sure you understand the treatments, services, and products being prescribed to you -- don’t be afraid to ask questions!
- Check that the explanation of benefits (EOB) and receipts provided by your insurer contain accurate information about the services or products you received
- If you notice anything suspicious, alert your insurer
HOW TO REPORT HEALTH OR DENTAL BENEFITS FRAUD
Benefits fraud affects everyone, and it’s our shared responsibility to report it when we see it. If you suspect that a coworker or health or dental service provider is committing benefits fraud, you can report it anonymously here.
Frequently Asked Questions
What are some examples of health and dental benefits abuse?
Benefits abuse can include many different scenarios such as (but not limited to):
Plan members and/or their dependents using all the annual maximums in their policy every year when products and services provided are not medically necessary.
Providers that are mixing marketing practices and treating patients (use of incentives).
Encouraging plan members to use all of their benefits before the end of the year which drives up plan utilization.
Providing unnecessary treatment to patients to maximize billings.
How can you protect yourself from the consequences of health and dental benefits fraud and abuse?
Learning how to use your benefits appropriately and how to recognize benefits fraud and abuse can help you refuse it and report it. If you suspect your health or dental service provider, coworkers, or others you know are encouraging you to submit a fraudulent claim, or something just doesn’t feel right, report it to your employer or insurance provider immediately. Report fraud anonymously here:
Can you report health and dental benefits fraud anonymously?
Yes. If you would like to report benefits fraud but you don’t want anyone to know that you are doing it, you can report it anonymously
How do you report health and dental benefits fraud?
Yes. If you would like to report benefits fraud but you don’t want anyone to know that you are doing it, you can report it anonymously here.
What are some examples of health and dental benefits fraud?
Benefits fraud can include many different scenarios, such as:
Billing for services that never occurred
Submitting a claim for the same service to multiple insurers to increase your reimbursement
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
Using your benefits to purchase items not covered under your benefits plan, such as purchasing non-prescription sunglasses and submitting the claim as prescription eyeglasses
Transferring unused benefits to others, such as using a dependent’s unused benefits to cover another’s health or dental expenses
Claiming prescription drugs on behalf of others who are not covered under your plan
Who commits health and dental benefits fraud and abuse?
Benefits fraud and abuse can be committed by health or dental service providers, plan members or both. You can become involved in benefits fraud without even knowing it. For example, a health or dental care provider could ask you to sign a blank claim form which they can use dishonestly later without your knowledge. If they do, you are involved in benefits fraud. While not fraud, a health or dental care provider may encourage you to “use it or lose it” when it comes to your benefits; if you are using your benefits to the maximum when products or services are not medically necessary, you are abusing your benefits.