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Healthcare Fraud

What is healthcare fraud?
Healthcare fraud is the intentional deception or misrepresentation of healthcare 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.

Currently, it is estimated that healthcare fraud costs Americans approximately $100 billion per year. 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 healthcare coverage
  • Enrolling individuals who are not eligible for healthcare coverage
  • Changing dates of hire or termination to expand dates of coverage

    How to report healthcare fraud?

    E-mail Oxford

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

    Write to Oxford at:

    Oxford Health Plans
    Special Investigations Unit
    P.O. Box 315
    Monroe, CT 06468

    How can members avoid and prevent healthcare fraud?

  • Ask your healthcare 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 Oxford Member 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 does Oxford do to fight fraud?

    Oxford's 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 healthcare companies. After receiving a report of fraud, the SIU investigates the allegation and works with the appropriate agencies/groups to resolve the issue.

  • Oxford Health Plans has united with other healthcare companies and state and federal agencies in an effort to prevent fraudulent acts from occurring. Oxford also educates and trains professionals on healthcare fraud.
  • You can learn more about Oxford's affiliations with state and federal fraud agencies.

    Links to learn more about healthcare 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 healthcare fraud. Visit NHCAA at www.nhcaa.org.
    • The Centers for Medicare and Medicaid Services (CMS): web site contains information on Medicare fraud and how to prevent it. Visit CMS at www.hcfa.gov.
    • AARP: website provides information on the different types of healthcare fraud and the consequences of committing Medicare fraud. Visit AARP at www.aarp.org.