Fraud and Abuse
What is health-care fraud, and why is it a problem?
Fraud occurs when a dishonest member or provider lies on an application or claim
form with the intention of receiving a payment from USAble Life group health insurance division to
which they are not entitled.
As stated in the Health Insurance Portability and Accountability Act (HIPAA) of
1996 (18USC, Ch. 63, Sec 1347):
Whoever knowingly and willfully executes, or attempts to execute, a
scheme or artifice — To defraud any health-care benefit program; or To obtain,
by means of false or fraudulent pretenses, representations, or promises, any of
the money or property owned by, or under the custody or control of, any
health-care benefit program, in connection with the delivery of or payment for
health-care services, shall be fined under this title or imprisoned not more
than ten years or both.
Fraud and abuse accounts for between 3 and 10 percent of the
annual expenditures for health care in the United States. We all pay the price through
higher premiums and health-care costs.
What are common types of fraud?
Providing false statements on an application;
Submitting claims for services that were not performed;
Misrepresenting services that were provided;
Providing medically unnecessary services.
What are the penalties for committing health-care fraud?
Health-care fraud is both a state and federal offense. As stated in the HIPAA
Act of 1996: (18USC, Ch. 63, Sec 1347), a dishonest provider or member is
subject to fines or imprisonment of not more than 10 years or both. Making
false or misleading statements on an application carries a maximum five-year
You can help!
Read your EOB (Explanation of Benefits) carefully. The EOB is your notification
that USAble Life group health insurance division has paid a claim under your health-benefit plan. Look for:
Incorrect dates of service;
Services that you did not receive;
Non-laboratory or non-X-ray providers that did not see or treat you.
Call the Fraud Hotline at 1-800-FRAUD21 any time day or night. All tips are kept strictly confidential.
Life group health
SPECIAL INVESTIGATIONS UNIT MISSION STATEMENT
The detection, prevention and elimination of fraud, abuse
and over-utilization are essential to maintaining a health care system that is
affordable for everyone now and in the future.
We aggressively investigate and pursue the prosecution of
the perpetrators of health care fraud, abuse and over-utilization, including
providers of medical and other related health services, agents, members and
We actively cooperate with criminal investigations
conducted by federal, state and local authorities, encourage education and
conduct awareness programs to alert our employees, members and the general
public to potential fraud or abuse.