Fraud & Abuse
Health Care Fraud and Abuse
Health insurance fraud is a criminal offense. It occurs when a person or entity
intentionally misrepresents facts in order to receive reimbursement for health
care services or supplies. Health care abuse is improper conduct that leads to
overpayment of health care benefits, with or without criminal intent.
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 insurance 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, inaccurate information on members’ permanent medical records 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 mining and 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.
In 2006 alone, HMSA’s anti-fraud efforts saved our members more than $5 million.
How you can help combat fraud and abuse:
- Keep accurate records of all health care appointments and treatments received.
- 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 medical provider blanket authorization to bill for services rendered.
- Ask your medical 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 (800) 776-4672, ext. 5166, toll-free from Neighbor Islands and the Mainland
By mail:
HMSA
Benefits Integrity Department
P.O. Box 860
Honolulu, HI 96808
If the situation involves Medicare, please call (808) 948-6228 on Oahu. HMSA staff will
investigate and contact you upon resolution of the complaint.