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Fraud and Abuse Prevention

Healthcare fraud and abuse costs billions of dollars every year:

  • · The Centers for Medicare and Medicaid Services (CMS) estimates that $97 billion is lost to fraud every year through federal health programs, mainly Medicare and Medicaid.

  • · The National Health Care Anti-Fraud Association estimates as much as 10 cents of every healthcare dollar is lost to fraud and abuse--that's more than $170 billion a year.

Healthcare fraud hurts everyone. In addition to higher premiums and increased out-of-pocket costs, healthcare fraud compromises health and safety, which can result in harm to patients. Billing scams increase costs for everyone, and medical identity theft can result in loss of your benefits and incorrect information in your medical records.

That's why it's important to learn more about healthcare fraud and abuse and what can be done to fight it.

What is healthcare fraud?

Healthcare fraud is a federal crime under most criminal codes, consisting of intentional deceit for the purpose of illicit gains. Healthcare abuse is similar activity or behavior, when knowing intent to obtain an unlawful gain cannot be established. Here are some examples of healthcare fraud and abuse:
  • · Submitting claims for services or supplies that were never provided

  • · Using someone else's medical insurance information to obtain services or supplies

  • · Falsifying signatures or medical records to support misrepresented services or supplies

  • · Unbundling services from a group to unlawfully increase medical payment

  • · Misrepresenting the location where services or supplies are provided

  • · Rendering medical care without a license

  • · Submitting duplicate claims

How to protect yourself from healthcare fraud

EMI Health partners with state and federal agencies, as well as advocacy organizations, to report, investigate, and reduce the incidence of healthcare fraud. Members play an important role in helping to identify and prevent fraud. We encourage you to take these steps to avoid becoming a victim of healthcare fraud:
  • · Safeguard your insurance identification card.

  • · Don't give your insurance number to marketers or solicitors.

  • · Ask your doctor to explain the reason for services.

  • · Beware of "free" medical services.

  • · Never sign a blank insurance form.

  • · After care, review your statement to verify accuracy.

  • · Report any discrepancies to your health insurance carrier.

  • · Report instances where copayments or deductibles are waived.

How to report suspected healthcare fraud

When you report a situation that may be fraud, you are doing your part to help save money for the healthcare system and prevent personal loss for yourself and others.

If you have a concern regarding possible fraud or abuse

Call EMI Health's 24-hour confidential anti-fraud hotline

(800) 380-8863

You can also

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If you have a concern regarding possible fraud or abuse