Fraud is an intentional deception or misrepresentation that the individual knows to be false or does not believe to be true and that the individual makes knowing that the deception could result in some unauthorized benefit to himself/herself or some other person.
Health insurance fraud is a quiet crime. There aren't any sirens or guns. The only victims are the American taxpayers, and most don't even realize they are being ripped off (e.g. a provider billing for services that weren't rendered).
Health care waste occurs when there isn't any intent to deceive for a monetary gain (as in fraud), but there is inappropriate utilization and/or inefficient use of resources (e.g. billing improper codes or billing separate services that should be bundled under the same code). Health care waste can lead to higher health insurance premiums or greater government spending.
Health insurance abuse occurs when an individual or entity unintentionally provides information to a health insurance company that results in higher payments than the individual or entity is entitled to receive (e.g. a provider's belief is that every patient should receive an x-ray every time they have an appointment).
Health care fraud is a major concern of ours and the entire health care industry. Some important facts about health insurance fraud are:
Financial Investigations and Provider Review
We take a proactive approach to detecting and investigating potential health care fraud, waste and abuse. Our Financial Investigations and Provider Review (FIPR) unit, a combination of the former Special Investigations Unit (SIU) and Provider Claims Review (PCR), is tasked with investigating all cases of health care fraud, waste and abuse that impacts us financially or the health and welfare of our members.
FIPR's mission is to support our company's mission of providing affordable, quality healthcare by ensuring that provider reimbursements are appropriate and by investigating and resolving suspected incidents of healthcare insurance fraud, waste or abuse to protect our company's assets. The department accomplishes this by utilizing data analysis techniques to identify aberrant claims, applying claim coding reviews and a variety of investigative techniques to assess the appropriateness of the provider payments and pursuing recoveries as necessary.
The role of the FIPR unit is to detect and investigate alleged fraud in all lines of business, generated both internally and externally. FIPR also conducts investigations involving Medicare C & D and internal investigations involving employee fraud.
A successful fraud prevention program requires the identification, investigation and resolution of potential fraud occurrences utilizing the following:
Types of Fraud Investigations
Sources of Evidence
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