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.
- 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.
Examples of fraud, waste and abuse by members, groups, providers, and other individuals or entities include, but are not limited to:
- 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
HMAA is committed to health care fraud, waste, and abuse prevention, detection, and reporting. We will conduct an investigation of allegations and cooperate accordingly with the appropriate parties, including government agencies. We have the right to access any records necessary to audit or investigate; however, the right to audit or inspect does not extend to information subject to legal privilege. Information identified, researched or obtained as part of the investigation will be treated as confidential and maintained solely for this specific purpose and no other.
HMAA retains the right to initiate a civil action to recover losses based on fraud, concealment or misrepresentation, and will utilize all legal actions available to rectify such situations.
- 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.