Health Care fraud is an intentional act of misrepresentation or deception that results in a higher benefit to the health care provider or health care member. Health care fraud results in the loss of millions of dollars every year from Medicare, Medicaid and private insurance programs. Beneficiaries pay for these losses through higher premiums, higher taxes and/or reduced services.
Examples of health care fraud include billing for services or goods not provided, including billings for no shows; falsifying certificates of medical necessity; falsifying plans of treatment and medical records to justify payment; billing separately for services which should be included in a single service fee, and, misrepresenting the diagnosis or procedures to maximize payments.
The Health Care Financing Administration (HCFA) requires intermediaries and carriers to send Medicare Summary Notices and Explanation of Medicare Benefits to beneficiaries in most instances. Beneficiaries receive these statements and summaries once a month for all claims processed during a 30-day period. Beneficiaries should review these statements and verify the information on the forms to help curb health care fraud.