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How to recognize benefits fraud

Release Date: 10/23/2018
Staff Reference: Shannon DeLenardo
1Watch out for providers who try to use your plan member information (i.e., usernames, passwords and other personal information) to charge for products and services you never received.
2Your explanation of benefits contains products or services not obtained by you or your eligible dependents. Always review your explanation of benefits and report any discrepancies to your employer.
3Your provider requests (supposedly for your convenience) that you sign a blank claim form. By having a signed healthcare or dental claim form, it is much easier to commit fraud in your name.
4Claiming for products and services not eligible as a benefit under your plan using benefit codes that are eligible for reimbursement (e.g., a spa day treatment submitted as massage therapy, designer sunglasses submitted as prescription glasses).
5You are offered cash or other incentives in exchange for your policy and certificate numbers. Report anyone asking for this type of information.
6Be on guard if your health care provider appears more concerned about obtaining a list of your covered benefits and the associated plan maximums than they are about providing you with the right product or service.
7With offers of incentives remember the “too good to be true” rule. Somebody is paying for those free services perhaps through hidden fees or built-in costs.
8Beware of providers that offer to bill a service as something other than the service received as a way to work around eligibility requirements or plan maximums.
9Shop around and ask questions to ensure the health care provider has the appropriate credentials for the services you are receiving.
10When paying for products/services, be wary of providers who ask if you have insurance. You or your plan sponsor may end up paying more than someone who does not have insurance.