What is the difference between benefits fraud and abuse?
Benefits fraud occurs when you intentionally submit false or misleading information to your insurance provider for the purpose of financial gain. Benefits fraud is a crime. Benefits abuse is a result of benefits being used when the products or services are not medically necessary. Although abusing your benefits is not a crime, preventing benefits abuse is equally as important as preventing benefits fraud when it comes to the sustainability of benefits plans.
What does health and dental benefits fraud and abuse look like?
Some people have become involved in benefits fraud and abuse because it was suggested by someone they trust, such as a health and dental service provider, a coworker or others they know. Learn what it looks like so you can stop it.
Take this quiz to learn what it means to commit benefits fraud and abuse. Select ‘Yes’ if you believe the scenario counts as benefits fraud or abuse, or ‘No’ if you do not believe it is benefits fraud or abuse.
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Frequently Asked Questions
Benefits fraud occurs when you intentionally submit false or misleading information to your insurance provider for the purpose of financial gain, and it can take many forms. Examples include (but are not limited to):
- Billing for health or dental services that were never received
- Submitting the same claim to multiple insurers to double your reimbursement
- Letting someone not covered by your plan use your benefits.
Benefits abuse occurs when you claim for excessive products or services beyond what would be considered as reasonable or medically required to maximize the benefits you feel you are owed. Examples include (but are 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.
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.
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: