How to recognize health and dental benefits fraud and abuse
Benefits fraud and abuse is not always easy to spot, especially when it is suggested by someone you trust. Look for these warning signs and report them 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 you didn’t receive, and are not covered by your plan
- 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
- Feeling encouraged to “use it or lose it” when it comes to your benefits (for example, using your benefits to their maximum when products or services are not medically necessary)
- Being offered cash or other incentives in exchange for your policy information
HOW TO USE YOUR BENEFITS APPROPRIATELY
Understanding how to use your benefits appropriately can help you guard against potential fraud or abuse. 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!
- Make sure 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
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.
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.
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.
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: report benefits fraud
You can report benefits fraud directly to your employer or your insurance provider, or if you don’t want anyone to know that you are reporting it, you can do it anonymously here.
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