You you are aware of healthcare fraud or feel you may be a victim, please contact our Fraud, Waste and Abuse hotline immediately.
Fraud, Waste and Abuse hotline
What is healthcare fraud?
Healthcare fraud is an intentional deception or misrepresentation made knowing that the misrepresentation could result in an unauthorized benefit.
The most common kind of fraud involves a false statement, misrepresentation or deliberate omission. Every year in the United States, more than $2.5 trillion is spent on healthcare. It is estimated that at least 3 percent of healthcare spending is lost to healthcare fraud. Loss due to fraud impacts our members, groups, taxpayers and government through increased healthcare costs, premiums and taxes. Healthcare fraud often hurts patients who may be subjected to unnecessary or unsafe procedures. Victims of medical identity theft might end up with incorrect information in their medical record that could impact future healthcare including the ability to obtain insurance because of a false medical profile.
The most common fraudulent acts include the following:
• Billing for services, procedures or supplies that were never provided
• The use of lost, stolen or borrowed health insurance cards by identity thieves
• Submitting a claim for a higher level of service than was actually provided
• Submitting or helping submit false or misleading information related to a claim
• Misrepresenting the nature of a service, procedure or supply
• Submitting an incorrect date of service
• Submitting an incorrect diagnosis
• Submitting a claim form for payment with the incorrect provider or patient listed on it
• Deliberately performing medically unnecessary services for financial gain
• Adding or leaving a non-qualifying individual, such as a domestic partner, spouse, dependent child or employee, on health insurance
The Summit Health Special Investigations Unit
Summit Health is committed to identifying, investigating and preventing healthcare fraud and abuse. Our dedicated Special Investigations Unit is staffed with experienced fraud investigators working exclusively for the benefit of our customers. Summit Health uses fraud detection tools including software that identifies inconsistencies prior to claims being paid. Safeguards are put in place to protect our members, groups and providers against healthcare fraud.
Help stop healthcare fraud
• Read your explanation of benefits carefully
• Make sure you can identify the date of service, provider and services rendered
• Report any suspicious activity immediately to the Summit Health Special Investigations Unit
• Never loan your health insurance card
Tips for seniors
• Never give out Medicare, Social Security, bank account or credit card numbers to a person who calls on the phone. Hang up the phone.
• No Medicare drug plan can ask a person for the above information over the phone
• No drug plan representative can come into your home uninvited, without an appointment
• No drug plan can ask you for personal information during its marketing activities
• You can enroll in a Medicare drug plan over the Internet, but the plan must send you a bill
• Report suspected fraud or abuse immediately,