Health Care Fraud and Abuse
Health care fraud occurs when a person or business intentionally misrepresents facts to receive reimbursement for health care services or supplies. It’s a criminal offense under state and federal laws and can result in hefty fines, loss of health care coverage, and/or criminal penalties — including jail time. It also results in higher costs for all HMSA members.
Types of fraud and abuse
Members, employer groups, providers, and other individuals commit health care fraud and abuse. Examples include:
- False statements on claim or billing documents.
- Claims for services that weren’t performed.
- Misrepresenting services sought or provided.
- Providing services that aren’t medically necessary.
- Using another person’s HMSA membership card or subscriber number, or allowing someone to use yours.
- Changing claim and billing documents.
- Making false statements on a health plan application or adding someone who isn’t eligible for coverage to a health plan.
- Withholding information about additional health care coverage.
The price of fraud and abuse
Everyone pays the price for health care fraud through higher health plan dues and out-of-pocket costs. It also results in reduced health plan benefits and coverage to make up for higher costs.
Health care fraud costs an estimated $68 billion to $226 billion annually. According to the Blue Cross and Blue Shield Association, each family in the U.S. pays more than $800 extra in health care costs every year because of health care fraud.
Penalties for fraud and abuse
Your health plan coverage will be canceled immediately if you are fraudulently enrolled due to misrepresenting or concealing facts on your enrollment form. You must reimburse HMSA for all claims HMSA paid on your behalf. HMSA also has the right to initiate a civil action to recover losses based on fraud, concealment, or misrepresentation.
HMSA’s anti-fraud efforts
HMSA takes all types of health care fraud very seriously. Our Benefits Integrity staff works to prevent fraud and recover money resulting from fraud. HMSA’s anti-fraud efforts save our members about $8 million a year. Also, the Affordable Care Act passed last year calls for stricter enforcement and penalties to combat enrollment fraud.
Prevent health plan enrollment fraud
You can help prevent enrollment fraud. Contact your employer or health plan if you need to remove a dependent from your health plan who is no longer eligible for coverage. For example:
- If you get a divorce, your former spouse may not be eligible to remain on your health plan.
- A child who is no longer considered your legal dependent may not be eligible to remain on your health plan.
Combat fraud and abuse
- Keep accurate records of all health care appointments and treatments.
- Carefully review your medical bills and HMSA Report to Member statements.
- Contact HMSA with any questions about payments or services claimed but never received.
- Never sign blank insurance claim forms.
- Ask your health care provider if the services you receive are medically necessary and if alternatives are available.
- Talk to your doctor if a treatment plan seems questionable or excessive. If you still don’t agree with the plan, don’t hesitate to get a second opinion.
- Protect your HMSA and Medicare membership cards and membership numbers. Give them only to those who provide you medical services.
- Report any suspicions of fraud to HMSA.
Report suspected fraud and abuse
If you suspect health care fraud or abuse, report it to HMSA’s confidential fraud hotline:
Benefits Integrity, 710/BI
P.O. Box 860
Honolulu, HI 96808