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Health Care Fraud & Abuse FAQs
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What is health care fraud? show/hide
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
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What is health care abuse? show/hide
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.
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What is the financial impact of health care fraud &
abuse? show/hide
- 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
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What other impact does fraud have on health care?
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- Falsification of patients’ diagnoses and/or treatment histories
- Theft of patients’ finite health insurance benefits
- Physical risks to patients
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Why it’s important to know about health care fraud
and abuse? show/hide
- 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
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What does fraud look like?
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- 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
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What can you do to help stop health care fraud and
abuse? show/hide
- 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
- Additional ways to report health care fraud and abuse:
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