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Fraud, waste and abuse

Healthcare fraud, waste and abuse affects everyone in the U.S. So let’s make sure you know what it is, how to spot it and how to help us prevent it. What is it exactly?

  • Fraud is when someone intentionally lies to a health insurance company, Medicaid or Medicare to get money.
  • Waste is when someone overuses health services carelessly.
  • Abuse happens when best medical practices aren’t followed, leading to expenses and treatments that aren’t needed.

When dishonest members or healthcare professionals engage in healthcare fraud, waste and abuse, it has an impact on you. This is a growing problem. This makes things harder for you and your loved ones because it can:

  • Increase your health risk
    • When you go to the doctor, your medical history and current symptoms help the doctor decide how to treat you. Sadly, some untrustworthy healthcare professionals may put your health at risk for the sake of their own benefit and suggest services or procedures you don’t really need.
  • Make you vulnerable to identity theft
    • This is similar to identify theft with credit cards. Medical identity theft is also a big problem. It costs time and money to resolve the issue. It can also compromise your safety if someone steals your information to get services or submit false claims. The thief could use up all your benefits, and then you wouldn’t be able to use them when you need care. Plus, a compromised health record could put you at risk for receiving treatments you don’t actually need or even keep you from getting life insurance in the future.
  • Prevent you from getting security clearances
    • Many jobs require a government security clearance. These are issued to honest and trustworthy people whose loyalty to the U.S. can be proven. If you’ve been a victim of healthcare fraud, waste and abuse and never resolved the issue, you won’t be able to get the clearances because of your compromised health records.
  • Put a dent in your wallet
    • The huge monetary losses increase the cost of your doctor visits and copays (if you have copays for your plan). The FBI estimates healthcare fraud is responsible for 3% to 10% of all healthcare costs. That’s about $75 billion to $250 billion total per year

These are some of the ways our investigative team fights scams:

  • Looking carefully at claims and the information in them to spot red flags
  • Keeping a close eye on doctors’ billing patterns for weird or suspicious charges
  • Working with other healthcare companies to track suspicious activity
  • Partnering with law enforcement to investigate potential fraud
  • Training all our employees to spot unusual claims

How can you help?

  • Watch out for freebies. If you are unsure if a service or extra benefit is for your plan, call the Member Services number on your member ID card.
  • Avoid identity theft. Don’t leave your member ID card out, and report it if it’s lost or stolen.
  • Review your explanation of benefits (EOB) if you get one in the mail. Your EOB is a snapshot of your doctor’s visit. When you receive it, make sure the services listed on it match the services you actually received.

Email this information to us at medicaidfraudinvestigations@healthybluela.com or call the member services number on your card. Please give as many details as possible about the situation. Tell us who, what, where, when, why and how, including:

  • The full name of the suspected member or doctor.
  • The doctor’s or member’s address.
  • The doctor’s or member’s telephone number.
  • Any information about the member or doctor that makes you believe they may be engaged in fraudulent activity.
  • The date(s) and time(s) related to the incident

You can also report anonymously. Call the member services number on your card. If you feel comfortable, it is helpful for us if you also give us your contact information so we can reach you if we have questions. Please provide your:

  • Full name
  • Address
  • Telephone number
  • Email address

Your identity will be protected to the extent allowed. Thank you for helping Healthy Blue’s efforts to find fraud, waste and abuse.