Frequently asked questions
There can be a lot of questions about how to identify fraud, waste and abuse — and when to file a report. Review these common questions to get answers and learn more.
Fraud is being dishonest on purpose to gain something of value or to get an unfair advantage.1
Waste is using more services than you need or practices that, directly or indirectly, result in unnecessary costs to the health care system. It is not generally caused by criminal actions, but by overusing resources.2
Abuse is an action that may result in unnecessary costs to the health care system. It’s when a person or entity has not knowingly or purposely misrepresented facts but receives a payment that they have no legal reason to get.3
Fraud and abuse affects all of us in many ways. The United States spends over $2.27 trillion on health care every year. Of that amount, the National Healthcare Anti-Fraud Association (NHCAA) estimates that tens of billions of dollars are lost to health care fraud and abuse. This loss directly impacts patients, taxpayers and the government through higher health care costs, insurance premiums and taxes.
Fraud and abuse can have a personal cost too. It can cause mistrust between doctors, patients and health care insurers. That’s because in many cases, fraud and abuse involve harmful actions, like getting prescriptions for the wrong medications, receiving improper medical services and being misguided by needless tests and diagnoses.
Health care fraud and abuse happen in many places and situations. Some examples can be provider, pharmacy, member or patient fraud and abuse.
It’s important to be aware of suspicious situations and be ready to report concerns. Take a look at the different types of fraud and abuse explained in the next section so you’ll have a better idea if a situation should be reported.
Here are some examples to help you know what is considered fraud and abuse.
Examples of potential provider fraud and abuse include:
- Submitting bills or claims for treatment or services that were never provided
- Claiming a false date of service to correspond with a member’s coverage period
- Billing for non-covered services using incorrect codes to attempt to have services covered
Examples of potential pharmacy fraud and abuse include:
- Incorrect pharmacy billing
- Bills for medication that was never dispensed
- Bills for brand name drugs, but dispensed generic drugs
- Prescription drug shorting
- Less than the prescribed quantity is intentionally provided and the patient is not informed
- Prescription forging or altering – done without the prescriber’s permission to increase the quantity of tablets or number of refills
Member or patient
Examples of potential member or patient fraud and abuse include:
- Submitting false claims
- Prescription stockpiling and unlawful sales of excessive services and goods for resale
- Concealing information about additional coverage in order to lower out-of-pocket payments, or receiving inappropriate reimbursement from multiple plans
- Identity theft
- Doctor shopping
- Multiple providers are seen in an attempt to obtain multiple prescriptions. Usually includes deception and can be driven by addiction, drug diversion for profit or both.
Yes. There are two ways to submit a report without identifying yourself.
- Contact the UnitedHealthcare Fraud Hotline number at 1-844-359-7736 and say that you would like to make an anonymous report
- Complete an online form
When you report health care fraud or abuse, any information you provide about yourself will stay confidential. That means that even if you give your name in the report, the health care provider(s) would not know that you reported them. However, you may also enter your complaint anonymously.
For help with your health plan, you can call the the number on the back of your ID card or contact the Member Services Call Center at 1-866-633-2446.
You can get help with questions about your health plan, including explaining bills, claims and coverage, helping you find network providers, like doctors, clinics or hospitals, or other questions and concerns.
- Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. 18 U.S.C. § 1347.
- Waste is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to a health care benefit program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.
- Abuse includes actions that may, directly or indirectly, result in unnecessary costs to a healthcare benefit program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.