Health Care Fraud and Abuse

Health care fraud is the intentional deception or misrepresentation of health care 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.

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 payment 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 health care coverage
  • Enrolling individuals who are not eligible for health care coverage
  • Changing dates of hire or termination to expand dates of coverage

Members - Avoiding and Preventing Health Care Fraud

  • Ask your health care provider questions about your treatment plan, diagnosis and services
  • Fill out, sign and date one claim form at a time
  • Question advertisements or promotions that offer free tests, treatments or services
  • Safeguard your health plan 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

GHC-SCW - Avoiding and Preventing Health Care Fraud

Upon notification of potential or confirmed health care fraud, Group Health Cooperative of South Central Wisconsin (GHC-SCW) investigates the allegation and works with the appropriate agencies and groups to resolve the issue.

More Information

The National Health Care Anti-Fraud Association (NHCAA) A cooperative effort of private-sector health insurers and public-sector law enforcement agencies to improve the prevention, detection, investigation and prosecution of health care fraud .

The Centers for Medicare and Medicaid Services (CMS) Information about Medicare fraud and how to prevent it.

AARP Information about types of health care fraud and the consequences of committing Medicare fraud

Reporting Health Care Fraud

Compliance Department
1265 John Q. Hammons Drive
Madison, WI 53717
(800) 605-4327

Additional Resources

Healthcare Fraud and Abuse Control Program Report
Avoiding Medicare Fraud and Abuse
How to Report Fraud and Suspected Fraud
Whistleblower Protection Program
Information for Victims of Identity Theft
FTC Identity Theft: What to do Right Away
Identity Theft and Credit Card Fraud: Protect Yourself
IRS: Protect Yourself From Identity Theft
Bureau of Consumer Protection: Privacy and Security