To protect yourself from fraud, thoroughly review your Explanation of Benefits, also known as an EOB, after you receive health care services. If you see something that looks inaccurate, you should report the situation right away.
Fraud: An intentional act of deception, misrepresentation or concealment in order to gain something of value. Examples include:
Waste: Over-utilization of services (not caused by criminally negligent actions) and the misuse of resources. Abuse: Excessive or improper use of services or actions that are inconsistent with acceptable business or medical practice. Refers to incidents that, although not fraudulent, may directly or indirectly cause financial loss. Examples include:
Some of the most common coding and billing issues we see are:
Up-coding refers to a provider’s use of Current Procedural Technology, also known as CPT, codes to bill a health insurance payer for providing a higher-paying service than was performed.
Example: Dr. Wrong diagnoses Mrs. Patient with a broken leg. Mrs. Patient’s broken leg was really just a hairline fracture. Dr. Wrong told her to be careful and stay off her leg for a few weeks and use crutches. However, Dr. Wrong submitted the bill to the insurance company claiming he put his patient’s leg in a cast. He later submitted a bill for removing that cast. Both billed services would pay him more than what he did to care for Mrs. Patient. By using different codes than what Dr. Wrong performed, he is committing up-coding.
Unbundling is a fraudulent practice in which a single all-inclusive service code, e.g. blood or chemistry panels, are broken down to individual service codes, resulting in higher payment by the insurance company. Two types of practices lead to unbundling. The first is unintentional and results from a misunderstanding of coding practices. The second is intentional and is used by providers to manipulate coding in order to maximize payment.
Possibly. Billing for services you did not receive is one of the most common types of health care fraud committed by providers. However, it may be a simple mistake. Always report erroneous charges to us, we will thoroughly research the charges and determine whether it is fraud or just a simple billing error.
No. This would be considered billing for services not provided, and you should report this to us immediately.
You are not required to identify yourself when reporting suspected fraud.
You should never be afraid to report your physician for suspicions of fraudulent billing or inappropriate behavior. We take every complaint seriously and are committed to protecting your confidentiality. Remember, if the provider is filing fraudulent charges under your coverage, then he or she is most likely filing false charges under other patients’ coverage as well.
If you suspect that a provider, supplier or care facility has committed a wrongdoing, including ethical issues, potential conflicts of interest, potential non-compliance issues, potential fraud, waste or abuse allegations, etc., (see above for definitions of fraud, waste and abuse), we ask that you report it to us immediately.
You may remain anonymous if you prefer. All information received or discovered by the Special Investigations Unit will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive information (e.g. state and federal authorities, Samaritan Health Services Legal Department, medical directors or senior management).
You may also report any suspected fraud, waste or abuse to an external agency. The following agencies will accept your report:
Protecting Medicare Future GenerationsIdentity Theft ProtectionDetecting Home Health FraudReporting Medical Transport FraudReporting Health Insurance Marketplace FraudQuestioning Free Medical SuppliesReporting Services Not Provided
Page Updated 6-7-2023
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