Oxford Health Plans > Healthcare Fraud

Health Care Fraud

What is health care fraud?
Health care fraud is the intentional deception or misrepresentation of health care transactions by a provider, employer group or member for the sake of receiving an unauthorized benefit or financial gain. Individuals convicted of this crime face imprisonment and substantial fines.

Health care fraud costs Americans approximately $80 billion per year according to estimates by the Federal Bureau of Investigation.. Learn more about How it Affects You.

Most Common Types of Fraud:

Provider Fraud:

  • Billing for services, procedures and/or supplies that were not provided
  • Billing that appears to be a deliberate application for duplicate payments of services
  • Billing for non-covered services as covered items
  • Performing medically unnecessary services in order to obtain insurance reimbursement
  • Incorrect reporting of diagnoses or procedures to maximize insurance reimbursement
  • Misrepresentations of dates, descriptions of services or subscribers/providers
  • Providing false employer group and/or group membership information

    Member Fraud:

  • Using someone else's coverage or insurance card
  • Filing claims for services or medications not received
  • Forging or altering bills or receipts

    Employer Fraud:

  • False portrayal of an employer group to secure health care coverage
  • Enrolling individuals who are not eligible for health care coverage
  • Changing dates of hire or termination to expand dates of coverage

    How to report health care fraud:

    Online Referral Form

    Call us toll-free at: 1-866-242-7727

    How can members avoid and prevent health care fraud?

  • Ask your health care provider questions about your treatment plan, diagnosis and services received.
  • Fill out, sign and date one claim form at a time.
  • Question advertisements or promotions that offer free tests, treatments or services.
  • Safeguard your health plan ID card and be careful about disclosing your insurance information.
  • Be sure your Explanation of Benefits (EOB) and medical bills are consistent with services received.
  • What do we do to fight fraud?

  • Our Special Investigations Unit (SIU) examines possible incidents of fraud. The SIU receives complaints (or leads) from a number of resources including members, providers, employers, law enforcement officials and other health care companies. After receiving a report of fraud, the SIU investigates the allegation and works with the appropriate agencies/groups to resolve the issue.
  • We have united with other health care companies and state and federal agencies in an effort to prevent fraudulent acts from occurring. We also educate and train professionals on health care fraud.
  • You can learn more about our affiliations with state and federal fraud agencies.

    Links to learn more about health care fraud:

  • The National Health Care Anti-Fraud Association (NHCAA): cooperative effort of private-sector health insurers and public-sector law enforcement agencies to improve the prevention, detection, investigation and prosecution of health care fraud. Visit NHCAA at nhcaa.org

  • The Centers for Medicare and Medicaid Services (CMS): website contains information on Medicare fraud and how to prevent it. Visit CMS at cms.gov.

  • AARP: website provides information on the different types of healthcare fraud and the consequences of committing Medicare fraud. Visit AARP at aarp.org.