Health Care Fraud and Abuse 

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Health care fraud and abuse is a national problem that affects each of us either directly or indirectly.  National estimates project that billions of dollars are lost to health care fraud and abuse on an annual basis.  These losses lead to increased health care costs and potential increased costs for health coverage.  HNS has a zero tolerance for fraud, waste, and abuse.

What is Fraud and Abuse?

Health care fraud is an intentional misrepresentation, deception, or intentional act of deceit for the purpose of
receiving greater reimbursement.  Abuse is reckless disregard or conduct that is inconsistent with acceptable
business and/or medical practices resulting in greater reimbursement.

While we know that most health care professionals are honest, there are a small number of people who try to
take advantage of both public and private payors by engaging in health care fraud and abuse.

Types of Health Care Fraud and Abuse

Health care fraud and abuse takes many forms.  The most common of these forms include:

Providers

• Billing for services that were not provided.
  
  
• Duplicate submission of a claim for the same service.
  
  
• Misrepresenting the service provided.
  
  
• "Up coding" - charging for a more complex or more expensive service than was actually provided.
  
  
• Billing for a covered service when the service provided was not covered.

Members/Insureds

• Using a member ID card that does not belong to that person.
  
  
• Adding someone to a policy that is not eligible for coverage (for example - grandchildren).
  
  
• Failing to remove someone from a policy when that person is no longer eligible (for example - a former spouse).

Tips to Prevent Fraud and Abuse

Your assistance is vital in helping to prevent fraud and abuse.  Simple tips that may help you prevent fraud and abuse include:

• Review your Explanation of Benefits to ensure your provider reported accurate dates of service, the types of
  services provided and included the correct name of the provider.
  
  
• Protect your insurance card and all personal information at all times.
  
  
• Report suspected fraud and abuse right away! 

How to Report Suspected Fraud and Abuse

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Telephone:

Call our confidential compliance hotline at 1-877-426-2411, extension 2.

We will make every effort to keep all information that we receive confidential.  If we all work together we can
prevent fraud and abuse and help reduce the cost of health care.