- Fraud – Conduct that involves intentional deception or misrepresentation, knowingly making a false claim, or other intentional or willful deception or misrepresentation known to be false or otherwise unlawful or improper, in order to receive some unauthorized benefit.
- Waste – An extravagant, careless or unnecessary utilization of or payment for health care services or supplies.
- Abuse – An activity or practice undertaken by an individual or entity that is inconsistent with sound fiscal, business or medical/dental practices and results in unnecessary cost to HMAA’s clients, reimbursement for health care services or supplies not medically necessary, or which fails to meet professionally recognized standards for health care.
Health Care Fraud, Waste, and Abuse
Health care fraud, waste, or abuse occurs when an individual or entity intentionally misrepresents facts to receive health plan coverage or reimbursement for health care services or supplies. Under state and federal laws, these occurrences are subject to loss of health care coverage, reimbursement, and/or civil or criminal penalties punishable by fines or imprisonment.
Definitions are as follows.
- Submitting claims for health care services or supplies not rendered
- Altering claims and/or billing documents
- Using another person’s membership card to receive health care services or supplies, or allowing someone else to utilize your membership card
- Making false statements on a member or group application for insurance or enrolling someone who is not eligible
- Withholding information regarding secondary health care coverage
- Providing health care services or supplies that are not medically necessary
- If a member or employer group is found to have violated a Fraud, Waste or Abuse law such as fraudulent enrollment due to misrepresenting or concealing facts on an enrollment form or group application, the health plan coverage will be canceled immediately and all claims paid on their behalf must be reimbursed by the member or group.
- Participating providers who are found to have violated a Fraud, Waste or Abuse law are often suspended and/or debarred from the provider network. In such situations, the provider’s participation agreement will be evaluated and will likely be terminated.