Health Care Fraud & Abuse FAQs

1.      What is health care fraud?

Fraud is defined as the intentional act of deceiving, concealing, or misrepresenting information that results in health care benefits being paid to an individual or a group

2.      What is health care abuse?

Abuse is defined as an incident that is inconsistent with sound medical or business practice; the intent is usually not present in instances of abuse.  Abuse can also include member practices that result in unnecessary costs to the health plan.

3.      What is the financial impact of health care fraud & abuse?

• Agencies that track health care fraud estimate costs at anywhere from 3% to 15% of all paid claims, with 10% being the most accepted figure

• Costs exceed $170 billion dollars a year

• Costs can impact each household’s health care costs by at least $200 each year

4.      What other impact does fraud have on health care?

• Falsification of patients’ diagnoses and/or treatment histories

• Theft of patients’ finite health insurance benefits

• Physical risks to patients

5.      Why it’s important to know about health care fraud and abuse?

• You can impact the costs associated with health care fraud and abuse

• Understand what it is and how you can report it – this can help save dollars!!

• Protect your medical history and health insurance benefits

6.      What does fraud look like?

• Diagnosis and treatment look different on an insurance explanation of benefits than on the physician’s statement

• Charges for lab fees and office visit are not the same day of the physician/lab services that were received

• Physician never charges an office co-pay during an office visit

• Samples of prescription drugs are charged to you

• A relative without health insurance asks to borrow your health insurance ID card

7.      What can you do to help stop health care fraud and abuse?

• Ask questions – if something doesn’t seem right get answers

• Contact the Customer Contact Center – the number is on the back of your Mercy Health Plans ID card

• Report your suspicions

• Ask your Customer Contact Representative to report to the Special Investigative Unit

• Call Mercy Health Plans Compliance Hotline – report anonymously if you wish - 1-877-349-5997

• Send an e-mail to SIUInvestigations@mhp.mercy.net at Mercy Health Plans

• See additional links to report fraud