Common Types of Fraud

Common Types of Fraud

There are at least as many types of fraud as there are types of people who commit it. Fraud in the health care system is no exception. Here are some ways a small percentage of people involved in the health care system cause problems for everyone else.

Provider Fraud

  • Billing for services not provided
  • Billing of "free" services
  • Incorrect reporting of diagnoses or procedures to maximize payments
  • Waiver of deductible and/or co-payment (unbundling, up-coding)
  • Over utilization of services
  • Kickbacks and bribery
  • Misrepresentation of dates or descriptions of services
  • Billing non-covered services as covered items
  • Eligible provider billing for services provided by ineligible provider

Subscriber Fraud

  • "Loans" an ID card to someone not entitled to use it
  • Enrolls someone not eligible for coverage on their BlueCross BlueShield of Tennessee contract
  • Alters amounts charged on claim forms or prescription receipts
  • Fabricates claims

Non-Subscriber Fraud

  • Using a stolen ID card for medical services

Groups

  • Providing false employer group and/or group membership information

Employees

  • Fabricates claims
  • Changes subscriber addresses to intercept subscriber payments
  • Providing false application data

Agents/Brokers

  • Falsifying group application data
  • Bribery and kickbacks

This process may result in administrative or civil action taken against the person committing the act, in an attempt to recover dollars lost. Any act believed to be of a criminal nature will be referred to the appropriate law enforcement agency for their consideration.