Health Care Fraud, Waste and Abuse Prevention

    Posted by Unity Health Insurance on July 10, 2017
    Health care fraud, waste and abuseUnity Health Insurance (Unity) is committed to improving the health of the communities we serve. This includes financial health as well as physical. Keeping you informed of ways you can prevent health care fraud, waste and abuse helps us reach this goal. We believe an informed member is a healthier one.

    What are health care fraud, waste and abuse?

    Health care fraud, waste and abuse are so widespread, that it’s a factor in the rising costs of all health care. So how can you avoid being a victim? Learning how to recognize and prevent health care fraud, waste and abuse are good places to start.

    Fraud is defined as intentional deception or misrepresentation made by an entity or person, including but not limited to a subcontractor, vendor, provider, member or other customer with the knowledge that the deception could result in some unauthorized benefit to a person or an entity.

    Some examples of fraud are –

    • Forged or altered applications or enrollment forms
    • Filing false claims or claims for services not performed
    • Misuse of a member ID card
    • Enrolling an individual without consent

    Waste is defined as an act involving payment or the attempt to obtain payment for items or services where there was no intent to deceive or misrepresent, but where the outcome of
    poor or inefficient methods resulted in unnecessary costs to the plan.

    Abuse is defined as incidents or practices that clash with accepted, sound business, fiscal or medical administrative practices. Abuse may, directly or indirectly, result in unnecessary costs to the health plan, improper payment, or payment for services that fail to meet professional standards of care or are medically unnecessary.

    Some examples of abuse are –

    • Billing for services that were not medically necessary
    • Over-charging for services or supplies
    • Misusing codes on a claim, such as upcoding or unbundling codes
    How you can prevent health care fraud

    As a Unity member, there are a number of ways you can prevent health care fraud, waste and abuse –

    • Never sign a blank insurance form.
    • Be careful about giving out your Social Security number.
    • Keep track of your plan’s paperwork and benefit documents, such as your Explanation of Benefits statements and letters received from Unity or your health care providers.
    • If it’s too good to be true, like “free” medical care, it might be fraud.
    • Apply the same safeguards to your member ID card as you would a credit card.

    How to report suspected fraud, waste and abuse

    If you have reason to believe that fraud, waste or abuse has happened, you have a few reporting options. You do not need to give your name or contact information and reports
    are kept confidential*.

    To report suspected fraud, waste and abuse, you can reach Unity Health Insurance’s Compliance department at –

    You can also report –

    • By visiting CMS’ State Contacts Database at cms.gov/apps/contacts
    • By contacting the Office of Inspector General’s (OIG) National Fraud Hotline –
      • Phone: (800) 447-8477
      • Fax*: (800) 223-8164
      • TTY: (800) 377-4950
      • Visit OIG online at oig.hhs.gov

    Note: While you may remain anonymous, in order to accept submissions for review by fax, the OIG Hotline requires a complaint to include a formal cover letter or the use of the downloadable complaint submission form, which is available online at oig.hhs.gov

    Topics: Member Newsletter

    Note - This is a public blog forum. If you have specific questions about your benefits, please contact Quartz Customer Service at 800.362.3310 or send us a secure email.