Fraud & Abuse Education
The majority of health care professionals and consumers are honest and act with integrity. But there is a small number who are not honest, and it is important for you to recognize fraud, its impact, and how you can help.
What is Health Care Fraud?
Health care fraud is the intentional act of deceiving, concealing, or misrepresenting information that results in health care benefits being paid to an individual or group. Medical or drug providers, individual members, and employer groups, as well as health insurance employees, can commit health care fraud. What does this mean to you? It means that someone is cheating the system to gain money or benefits that he or she is not entitled to. Individuals convicted of health care fraud can be subject to fines and or imprisonment.
What is the Impact of Health Care Fraud?
Health care fraud results in increased cost of health care benefits. The National Health Care Anti-fraud Association (NHCAA) estimates that conservatively 3% of all health care spending ($68 billion) is lost to health care fraud. How does this affect you?
- Higher premiums
- Higher costs to provide care
- Possible compromise in quality of care
Examples of Provider and Member Fraud
- Provider bills for services, procedures, and/or supplies that were not provided.
An actual case involved a skin doctor who regularly billed insurers for acne surgery while only doing facials or no work at all. He had staff beauticians perform surgery. The doctor paid $100,000 to settle the charges.
- Giving money, products, or services as an incentive for providing member referrals.
This process is called “kickbacks” and, as you would expect, is illegal. An actual case involved a large drug company that provided free samples of a high profile drug to doctors and encouraged them to bill their patients’ insurance. The company believed this would lead to a large increase in future prescriptions.
- Routine waiving of patient copayments or deductibles then over billing the insurance plan.
In waiving the patient’s copayment, the doctor may compensate for the loss of reimbursement by charging the insurance company a rate higher than normal or over billing to receive a greater than normal reimbursement.
- Using someone else’s medical insurance card.
This may be a situation involving identity theft. Regardless, the individual is providing a false identity and inflating the future cost of health insurance benefits.
- A member filing for reimbursement on services or medications that were not received or performed.
What is Coventry Health Care Doing About This Concern?
Coventry Health Care has a Special Investigations Unit (SIU) designed to monitor and investigate suspicious activities within its health plans. The SIU works closely with state and federal law enforcement agencies, other insurance companies, and the provider community to detect and prevent health care fraud. We staff the SIU with clinical professionals, claims investigators, and data analysts trained to detect fraudulent and abusive activity.
How Can You Help?
- Review your Explanation of Benefits (EOB) and, if available, compare it to your medical bill. If there is any difference between the two, contact Customer Service at the phone number provided on your EOB or your health insurance card.
- Protect your health insurance information. Do not let anyone else use your health insurance card.
- Don't let anyone use your Social Security Number.
- Be suspicious of free medical services that require your health insurance information. Remember, if it is free, there isn't any need to share insurance information.
- Alert your health insurance company of any providers who routinely waive your copayment or deductible.
- Never sign a blank insurance claim form.
Report Suspected Fraud, Waste and Abuse
Special Investigation Unit (SIU)
Coventry and its subsidiaries are dedicated to conducting business according to the highest standards of ethical conduct and in compliance with all federal, state, and local laws governing its business.” Coventry has adopted a Code of Business Conduct and Ethics to reflect these standards of conduct. We post a copy of the Code on Coventry’s website.
Accordingly, Coventry is committed to the detection, correction, and prevention of Fraud, Waste and Abuse in each of the benefit programs that make up Coventry Health Care. The SIU, in cooperation with each of the health plans and other departments at Coventry, has designed policies and procedures to assist in the fulfillment of these objectives. The SIU leads the enforcement of these policies and procedures through investigations, training, and awareness efforts.
Report Suspected Fraud, Waste, and Abuse
The SIU has a dedicated hotline for reporting fraud, waste, and abuse. Call the Hotline at (866) 806-7020. You will be prompted to leave a message when you call. You may also report suspected FWA by sending an e-mail to CoventrySIU@cvty.com or a fax to (724) 778-6827.
You may also report suspected violations to the Coventry Health Care Comply Line by calling (877) 242-5463 (877-CHC-LINE). We staff the Comply Line 24 hours a day. You may remain completely anonymous. You are legally protected from retaliation for raising questions or reporting suspected violations in good faith.
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