What is health care fraud?

Health care fraud is the deliberate submission of false information to gain undeserved payment on a claim.

What is abuse?

Abuse involves a questionable practice inconsistent with accepted medical or business policies. While not an intentional misrepresentation, it may result in unnecessary costs.

Who can commit fraud or abuse?

Anyone involved in health care (e.g., patients, doctors, hospitals, clinics, labs).

What are the warning signs?

Items or services on your Explanation of Benefits (EOB) which:

• You didn't receive.
• Are different from those you received.
• Are unnecessary, inappropriate, or of questionable medical benefit.
• Are billed under a different name than the individual who provided the service.

A health care provider who:

• Routinely waives your deductible and coinsurance costs.
• Offers "free" items or services to you, but then bills them to WPS.
• Always requires his or her patients to pay the entire bill on the day the service is provided.
• Any person (other than a covered dependent) who uses your insurance identification card to obtain medical care.

How does fraud and abuse affect you?

Fraudulent and abusive claims can affect your health care history. If a claim is filed for a service you didn't receive, this could:

• Affect your future ability to obtain life or health insurance.
• Increase insurance premiums.
• Affect the health care received from other providers.

How can you help stop fraud and abuse?

• Know the warning signs.
  
• Read your EOB and make sure all of the services listed were received.
  
• Never give your health insurance number to anyone over the phone.

How can I report Fraud or Abuse?

Use our online form or call our toll-free fraud and abuse hotline: 1-888-766-4681

Where can I get more information?

• Learn about our Special Investigations Unit

Visit the websites below:

• Coalition Against Insurance Fraud
  
• Health and Human Services Office of Inspector General
  
• National Health Care Anti-Fraud Association
  
• State of Wisconsin Department of Regulation and Licensing