Fraud, waste, and abuse

Everyone is concerned about rising healthcare costs and many assume there’s nothing they can do about it. However, up to 3 percent of healthcare costs are estimated to be wasted by overstated, double-billed, or otherwise fraudulent charges. We all pay for these excesses. Providence Health Plan is committed to the prevention, detection, and reporting of healthcare fraud, waste, and abuse. You, our health plan members, are a vital part of helping us address this problem. In the process, you are protecting yourself from unnecessary higher costs and potentially more serious concerns, such as identity theft.

Defining healthcare fraud, waste, and abuse

Fraud is knowingly and willfully attempting to falsely obtain money from any healthcare benefit program. Fraud is distinguished from abuse in that there is clear evidence that the acts were committed knowingly, willfully and intentionally or with reckless disregard.

Waste is healthcare spending that can be eliminated without reducing the quality of care, such as overuse (prescribing too many antibiotics), underuse, and ineffective use of treatments or medications. It is also the inefficiency in redundant testing, delays in treatment, and making processes unnecessarily complex.

Abuse is defined as improper actions or billing practices that creates unnecessary costs.

A $60 billion problem

The United States spends more than $2 trillion annually on healthcare. Conservative estimates are that 3 percent, or more than $60 billion each year is lost to fraud, waste, and abuse.

While the vast majority of physicians and other healthcare providers are honest and legitimate, it is the few that aren’t that cost all of us money and negatively affect healthcare. Even honest providers can make billing mistakes; it’s up to everyone to help address this issue.

What fraud, waste, and abuse mean to you

The costs affect patients, taxpayers and government through higher healthcare costs, insurance premiums and taxes.

Your medical record could contain incorrect information about your medical history.

Falsely billed procedures as a result of medical identity theft and fraud create incorrect information in your medical record, which can make it difficult for you to get insurance coverage in the future.

In extreme cases, unnecessary or unsafe procedures could cause injury or death.

Spotting fraud, waste, and abuse

• An individual or organization calls you, saying they represent Providence Health Plan, Medicare or other government entity and asks you for insurance information, Social Security number, bank account number, credit card number or other personal information.
• Someone asks you to sell the use of your medical insurance card or prescription drug card.
• Someone asks you to get drugs for them by using your prescription drug card.
• You were encouraged to sign up for another plan and disenroll from your current plan with an offer of cash or a gift worth more than $15.
• Your pharmacy did not give you all the drugs that should have been covered (your doctor ordered 30 and you were given 25) or you were charged for drugs you did not receive.
• You received a different drug than your doctor ordered, not including generic substitutes.
• You believe you were charged more than once for your copay or deductible.
• You are billed for the services of a provider that you did not see.
• You are charged for services you did not receive or you are billed for services on dates that you were not with the provider.

These examples are only a small list of possible fraud, waste and abuse situations. Some of these could be honest mistakes by your providers. If you are uncertain about whether a situation was fraud, waste. or abuse, always feel free to call Providence Health Plan.

Four ways to stop fraud, waste, and abuse

1. Read

By reading your benefits information or policy you will know what services are supposed to be covered. By reading your explanation of benefits (EOB) that are mailed to you after you have received services, you will know if the date of service is correct (did you have services on that date?), if the service itself was performed, or if any services appear that do not seem correct. If you have questions about the information on the EOB, you should contact your provider’s office and ask for an explanation, it may be a simple billing error. If the provider does not resolve the issue, contact Providence Health Plan using the information below.

2. Be aware

Be aware that “free” offers of services or equipment are often fraud schemes designed to bill you and your insurance company illegally for treatments you will not receive.

Be aware that offers of “knowing how to bill” to get an uncovered service or item paid for is likely not legitimate.

Be aware that allowing others to use your medical insurance card is fraud and you can be prosecuted.

3. Protect

Protect your health insurance, Medicare, or Medicaid card like it was your credit card. Report a lost or stolen card immediately.

Do not give out your health insurance card or policy numbers to door-to-door salespeople or phone solicitors.

You can check your medical and pharmacy claims any time online through, our secure online portal. Like doing a periodic credit check, this enables you to verify that the claims under your name are yours and were filed correctly. (Not all online services are available to all members. Medicare and Oregon Health Plan members, please call customer service.) If there is a claim or a prescription that does not look right, you can call customer service and/or your provider.

4. Report

If you still have questions or concerns that fraud has occurred, contact Providence Health Plan using the information below.    

Reporting fraud, waste, and abuse

You have several options when reporting fraud, waste, or abuse:

• Fill out this online form
• Call Providence Health Plan's Special Investigations Unit confidentially at 503-574-8505 or toll-fee at 1-888-233-4101
• Fill out this external referral form (PDF). Print it and send it to us by secure fax or mail your letter to:
  
  Special Investigations Unit
  Providence Health Plan
  P.O. Box 3150
  Portland, OR 97208-3150