Fraud & Abuse
Health Care Fraud and Abuse
Health care fraud is a criminal offense. It occurs when a person or entity intentionally
misrepresents facts to receive reimbursement for health care services or supplies.
Health care abuse is improper conduct that leads to overpayment of health care benefits.
Types of Fraud and Abuse
Members, employer groups, providers and other individuals in the continuum of care
commit health care fraud and abuse. Examples include:
- False statements on claim or billing documents.
- Claims for services not performed.
- Misrepresenting services sought or provided.
- Providing medically unnecessary services.
- Using another person’s HMSA member ID or allowing someone to use yours.
- Altering claim and billing documents.
- Withholding information about additional health care coverage.
The Price of Fraud and Abuse
Everyone pays the price of health care fraud and abuse. Health plans often recover
these losses through rate increases, higher copayments or reduced benefits.
Also, committing fraud can result in inaccurate information on members’ permanent
medical records which can potentially jeopardize their future treatment and care.
HMSA’s Anti-fraud Efforts
Our Benefits Integrity department investigates all fraud reports and uses claims
processing safeguards, case review, data analysis, and random provider audits to
monitor benefit transactions. These investigations may result in simple resolutions,
civil action to recover improper payments, or criminal case referrals to state and
federal legal authorities. An integral part of Benefits Integrity’s anti-fraud
efforts is its ongoing fraud investigations in coordination with state and federal
law enforcement agencies.
In 2009, HMSA’s anti-fraud efforts saved our members more than $8 million.
How you can help combat fraud and abuse:
- Keep accurate records of all health care appointments and treatments.
- Carefully review your medical bills and HMSA Report to Member statements.
- Contact HMSA with any questions about payments or services claimed but never received.
- Never sign blank insurance claim forms.
- Do not give a health care provider blanket authorization to bill for services rendered.
- Ask your health care provider if the services you receive are medically necessary
and if alternatives are available.
- Protect your HMSA member or Medicare identification number. Give it only to those
who will be providing you with medical services.
- Report any suspicions of fraud to HMSA.
Reporting suspected fraud and abuse
If you suspect health care fraud or abuse, report it to HMSA’s Benefits Integrity
department.
By telephone:
(808) 948-5166 on Oahu
1 (888) 398-6445, toll-free from Neighbor Islands and the Mainland
By mail:
HMSA
Benefits Integrity Department
710/BI
P.O. Box 860
Honolulu, HI 96808