Consumers’ Frequently Asked Questions
The mission of the National Health Care Anti-Fraud Association (NHCAA) is to protect and serve the public interest by increasing awareness and improving the detection, investigation, civil and criminal prosecution and prevention of health care fraud and abuse. However, NHCAA does not investigate fraud or insurance payment issues. Rather, NHCAA is a private-public partnership against health care fraud. We provide a venue where private insurers and government entities can work together to address this serious problem and provide unparalleled learning opportunities related to combating health care fraud and abuse.
Ask to speak to your provider’s billing department to discuss the incorrect charges, and if possible, it’s always best to go in person. If you are unable to resolve your issue with your provider, contact your insurer and request to speak to their Special Investigations Unit or Fraud Department to investigate the billing issue. Some insurers have a fraud hotline number that can be found on the back of your insurance card, their website, and/or your Explanation of Benefits.
If you don’t have insurance and believe there is fraud being committed, contact your state’s medical board to report the issue.
Common Examples of Billing Issues
- Billing for services that were not actually performed or provided;
- Billing for services that were performed by another provider;
- Billing for non-covered services using an incorrect diagnosis code in order to have services covered;
- Billing a patient more than the co-pay amount for services provided for under the health insurance plan;
- Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary;
- Upcoding – billing for a more costly service than the one actually performed;
- Unbundling – billing each stage of a procedure as if each were a separate procedure; and
- Waiving patient co-pays or deductibles and over-billing the insurance plan.
Ask to speak to the hospital billing department. It’s always best to go in person, if possible, to resolve billing issues. If the issue is not resolved and you still believe you were charged for tests or services you didn’t receive, request a copy of your medical file/treatment record from the hospital and compare the file with the list of charges on the bill. If you were billed for tests, the results should be in the medical file/treatment record. Also, there should be notes in the file concerning the services provided to you as a patient. You should then again speak to the hospital billing department or hospital patient advocate.
If you are still unable to resolve the billing issue with the hospital, contact your health insurance plan and request to speak to their Special Investigations Unit or Fraud Department to investigate the billing issue. Some insurers have a fraud hotline number that can be found on the back of your insurance card, website, and/or you Explanation of Benefits.
Make sure to have your facts, dates, names, treatment details, bills and other evidence of potential fraud readily available when you call or make a report.
The Special Investigations Unit of your insurance company is the best place to start. Contact Medicare or Medicaid if you’re a recipient of these benefits. If you don’t have insurance and believe there is fraud being committed, contact your state medical board. Most have electronic reporting capabilities that allow you to make a report on line.
We suggest that you contact your insurance company and ask to speak to their Special Investigations Unit or Fraud Department. Contact Medicare or Medicaid if you’re a recipient of these benefits. You can also contact your state’s insurance fraud bureau. Make sure to have your facts, dates, names, treatment details, bills and other evidence of potential fraud readily available when you call or make the report.
You may be the victim of a health insurance scheme. In addition, if you provided personal information, such as bank/checking account data, you also may be the victim of identity theft. You should: 1) Contact your bank and determine if here was any activity in your account. 2) Create an identity theft report with the Federal Trade Commission (FTC). 3) Contact the three credit reporting companies to report your potential identity theft.
- Equifax, 1-800-525-6285
- Experian, 1-888-397-3742
- TransUnion, 1-800-680-7289
Consumers should be cautious and not respond to solicitations to buy health insurance received on the phone or via fax. Even posters on cafeteria walls at places of employment in some cases have been found to be fraudulent. Contact your state’s department of insurance to report the fraudulent health insurance scheme. The insurance department also will have a listing of properly licensed health insurance plans.
Ask to speak to the hospital billing department and/or the billing department of the emergency room practice group. It’s always best to go in person, if possible, to resolve billing issues. If the issue is not resolved and you still believe you were charged for tests or services you didn’t receive, request a copy of your medical file/treatment record from the hospital and compare the file with the list of charges on the bill.
If there are charges for items/services not provided, you should again bring that to the attention of the hospital’s billing department or patient advocate. It would be a good idea to write up the discrepancies so that, if your bill is sent to a collection agency, you can submit the write up to the agency putting it on notice that you are contesting some of the charges. If you are unable to resolve the issue with the hospital directly you can submit a report to your state’s hospital association.
For most tests, there are two components: the test itself (technical component) normally done at a diagnostic center and reading/reviewing the results (professional component), which, for example, may be done by a radiologist. Your insurance company can explain the charges to you.
However, if you still believe there has been fraud, contact your insurer and request to speak to their Special Investigations Unit or Fraud Department to investigate the billing issue. Some insurers have a fraud hotline number that can be found on the back of your insurance card, website, and/or your Explanation of Benefits. Contact Medicare or Medicaid if you’re a recipient of these benefits.
Fake Health Insurance Policies: Scammers may deceptively market fake health insurances policies and create fake Web sites that claim to sell coverage in the Health Insurance Marketplace created under the Affordable Care Act. The bogus policies and Web sites target seniors or low-income consumers to gain their personal information. These scammers will pose as government employees and will con consumers into divulging their bank account numbers in order to sign up for fake health care plans. Consumers are being enticed by cheap policies – sometimes costing as little as $29.95 per month.
Fake Navigators*: Individuals or companies pretend they’re official navigators helping you find coverage in the Health Insurance Marketplace (also known as Health Insurance Exchanges) setup under the Affordable Care Act. These fake Navigators may knock on your door, make cold-calls via telephone, or setup phony websites to lure in consumers. Some common navigator scams you might see:
- Charge a “signup fee” and ask for your credit card and banking account numbers. Under the law, navigators are not allowed to charge for their services.
- Show you fake online insurance applications or a bogus online signup portal on their laptop. The portal may request your sensitive financial information to “sign you up for the exchange.”
- Sell fake insurance. You’re left with large medical expenses when the worthless policy refuses to pay the bills.
- Phony exchange websites. Bogus sites might look real – you’ll see the state seal, the word “Exchange” and your state name prominently on the homepage. Thieves also might copycat a real exchange site. To be sure that you have found your state’s Health Insurance Marketplace, you should visit HealthCare.gov online to apply for insurance. You will be redirected to your state’s Marketplace.
- Email pitches. Spam emails arrive, supposedly from your exchange. You open the link and it takes you to a fake exchange or other “official” signup engine that requests your sensitive financial information. Opening the link also might install malware on your computer.
*A Navigator is an individual or organization that’s trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including completing eligibility and enrollment forms. These individuals and organizations are required to be unbiased. Their services are free to consumers.
Protect Yourself: Consumers can better protect themselves from ACA related scams by following these suggested preventive measures:
- Visit HealthCare.gov and get informed about the Affordable Care Act and the Health Insurance Marketplace.
- If someone claiming to be associated with the new Marketplaces or another federal program asks you to wire money, give out your bank account number, or load funds onto a prepaid card, it’s a scam.
- If you received an unsolicited phone call, email, or fax claiming that you need to purchase a new Medicare card or update your personal information (such as your Social Security number, date of birth, or other sensitive information) because “it’s the law,” hang up and submit a complaint to the Federal Trade Commission.
- Be careful of phishing sites made to look like official Health Insurance Marketplace (Exchange) websites. These sites simply exist to load malware onto your computer or collect your personal information.
- In the event that you inadvertently divulge personal information, inform your banks, credit card providers, and the three major credit bureaus so that they can be on the lookout for potential identity thieves.
– Equifax, 1-800-525-6285
– Experian, 1-888-397-3742
– TransUnion, 1-800-680-7289
When contacting your health insurer’s SIU, Medicare, Medicaid, or state agency to report potential fraud you should be prepared with the following:
- Be sure to include as much information as possible
- Full details of the suspected scam
- Dates, names
- Organizations involved, including phone numbers and addresses (if relevant)
- Insurance company or companies that were defrauded or did the defrauding (if relevant)
- Amount of money you think was lost
- Documents and other written material you may have
- Other information you think is helpful