Health care fraud and abuse increases costs for everyone. That’s why it’s important for all of us to learn more about it.

What Is Health Care Fraud and Abuse?
Health care fraud is the intentional misrepresentation of a fact on a health care claim in order to receive reimbursement from a health plan. Fraud is also the act of misrepresenting health care services or supplies.

Health care abuse is any activity that abuses the health care system but does not meet the statutory definition of fraud. Examples include over-utilization of services, changing procedure codes and unbundling services.

Who Commits Fraud?
Health care fraud can be committed by a member sharing his health plan ID card with others or a provider charging for services that were not provided. Fraud can occur within any of the following groups:

• Members
• Non-members
• Employer groups
• Employees
• Providers
• Brokers/Agents
• Claims Processors

What Is the Real Cost of Health Care Fraud?
The true cost of health care fraud is astounding:

• In 2004, the Centers of Medicare and Medicaid Services stated that approximately $85 billion – five percent of the $1.7 trillion in United States health care expenditures in 2003 was lost to fraud.
• The National Health Care Anti-Fraud Association estimates that of the nation’s annual health care outlay, at least 3 percent, or $51 billion, is lost to fraud. Other estimates place the loss as high as 10 percent, or $170 billion.

Who Is Battling Health Care Fraud?

• Private Insurers, such as Asuris Northwest Health
• Blue Cross Blue Shield Association Anti-Fraud Organization
• National Health Care Anti-Fraud Association (NHCAA)
• Legislative Health Care Initiatives, including special prosecutors for health care fraud
• Governmental Agencies, such as:
  • U.S. Attorney's Office
  • Federal Bureau of Investigation
  • U.S. Postal Inspector
  • Food and Drug Administration (FDA)
  • Office of the Inspector General
  • State Agencies