Medicare Fraud
Mutual of Omaha Rx (hereinafter, the Plan) has ways to fight fraud, waste, and abuse.
The Problem of Health Care Fraud
The National Health Care Anti-Fraud Association (NHCAA) website reports that the United States spends more than $2.5 trillion on health care every year and estimates that tens of billions of dollars are lost to health care fraud, waste and abuse. Loss impacts patients, taxpayers and the government because it leads to higher health care costs, insurance premiums and taxes. Healthcare fraud often hurts patients who may receive unnecessary or unsafe health care procedures or who may be the victims of identity theft. Healthcare fraud is not a victimless crime and can have long-lasting devastating effects.
What is Health Care Fraud?
Healthcare fraud is knowingly and willingfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by or under the custody or control or any health care benefit, program.
According to the NHCAA, whether you have health insurance through your employer or you purchase your own insurance policy, health care fraud causes higher premiums and out-of-pocket expenses for patients, and reduces benefits or coverage.
Healthcare fraud also has a human face to it. These are people who may have been taken advantage or subjected to unnecessary or dangerous medical procedures. A patient’s medical records may be stolen and used to fraudulently bill insurance companies; this may affect a patient’s medical history.
What are Examples of Health Care Fraud?
- A health care provider bills for medical services, supplies or items that were not provided
- A health care provider bills for a more expensive service or procedure than what was actually provided or performed
- A health care provider performs medically unncecessary services to obtain the insurance payment
- A health care provider misrepresents a non-covered service as medically necessary to obtain the insurance payment
- A health care provider falsifies a patient’s diagnosis to justify tests, surgeries or other procedures that are not medically necessary
- Payment for medical referrals
- A health care provider or pharmacy charges a beneficiary a price over the copay amount
- A health care provider or pharmacy waives the patient's copay amount and overbills the insurance plan to recoup the cost
- A pharmacy bills for prescriptions that were not dispensed
- A pharmacy dispenses a generic drug, but bills for a brand-name drug
- A pharmacy shorts prescriptions (e.g., billing for 60 tablets, but dispensing 30)
- A pharmacy adds unauthorized refills to prescriptions
- A pharmacy, beneficiary, or policyholder forges or alters a prescription
- A beneficiary or policyholder misrepresents personal information such as identity, eligibility, or medical condition in order to illegally receive a benefit
- Someone steals or purchases a beneficiary's or policyholder's personal information to submit false or phantom claims to obtain the insurance benefit
- A beneficiary or policyholder allows somebody else to use his or her health benefits to obtain medication and/or medical services
- Somebody pretends to represent Medicare, the Social Security Administration, or an insurance plan for the purpose of obtaining personal and/or financial information
Phishing Schemes for Bank Information and Identity Theft
The Plan CANNOT ask for member identification numbers (e.g. bank account numbers, credit card number, Health Insurance Claim Number [HICN]) EXCEPT as required to verify membership, determine enrollment eligibility or process an enrollment request). The Plan will NEVER ask for your Social Security Number.
Phishing is a type of theft used by fraudsters to lure people into a false sense of security with the intent to steal a person's private information by phone calls, emails or copy-cat websites.
Identity theft happens when someone steals a person's information and uses it without his or her permission or knowledge. Medical identity thieves may use a person's name and personal information such as his or her health insurance number to make doctor's appointments, obtain prescription drugs, and file claims with his or her insurance company. This may affect the person's health and medical information and can potentially lead to misdiagnosis, unnecessary treatments, or incorrect prescription of medication. There are many ways an identity thief can obtain a person's health information, such as: paying for it, offering free services, supplying food or gifts, or providing free "health screenings."
The Office of Inspector General of the U.S. Department of Health and Human Services website provides the following suggestions to protect yourself against fraud:
- Treat your Medicare card, Social Security card, and insurance ID card like you would your most valuable possessions so that they don’t fall into the wrong hands.
- Review your Explanation of Benefits (EOB) when you receive it in the mail. Look for:
- Charges for services, drugs, equipment, and/or supplies you did not get
- Billing for the same service, drug, equipment, and/or supplies twice
- Services that were not ordered by your doctor
- Review the dates of services and verify the charges are familiar
- Do not give out personal information over the phone or through mail unless you have initiated the contact or are communicating directly to your insurance company.
- Be cautious of providers who offer "free" testing or screening but require your Medicare and/or insurance card first. This may be a scam to get your personal information.
- Avoid using a health care provider or pharmacy who tells you that the item or service is not usually covered, but they know how to bill Medicare to get it paid for.
- Do not accept items in the mail that you did not order - you are under no obligation to accept items that you did not order and should refuse delivery and/or return the items to the sender.
Our Commitment
The Plan is committed to fighting health care fraud, waste, and abuse.
We have a dedicated staff whose mission is to protect our policyholders, providers, employees, other related parties, and the Medicare Trust Fund by administering a plan to prevent and detect fraud, waste, and abuse. The staff works to investigate all allegations, correct offenses, recover lost funds, and will partner with Federal and state agencies to prosecute violators to the fullest extent of the law.
Help Fight Fraud
Here are some simple measures to protect yourself and help the fight against health care fraud:
- Report all suspicious acts regarding your health care, and call immediately. The SIU will investigate all allegations and complaints
- Maintain good records of all your medical care and closely review the medical bills you receive
- Read and carefully examine your Explanation of Benefits (EOB), health care policy, and any paperwork you receive from your insurance company
Who To Contact
If you suspect someone of committing insurance fraud against the Plan or think you may be a victim, please report immediately the suspicious activity to the Compliance Department:
By Phone:
Fraud, Waste, and Abuse Hotline – 866-898-2898
By Email:
MedAdvantage.Compliance.Officer@mutualofomaha.com
In Writing
Medicare Compliance Department
3300 Mutual of Omaha Plaza
Omaha, NE 68175
All communication are confidential and may be anonymous.