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Types of fraud

Member fraud—committed by a plan member.

Examples include forging receipts, submitting a claim for services not received, sharing benefits with others, misrepresenting services and identity theft.

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Provider fraud—committed by a health care provider.

Examples include submitting false claims, claiming for services more expensive than what was provided, providing incentives to plan members, misrepresenting services and submitting claims under another person’s name.

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Collusion—committed by a plan member and provider working together.

Examples include submitting for services or products that are not supplied, claiming for a more expensive service than what was provided and claiming under another plan member’s name.

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What does benefits fraud look like?

Benefits fraud can come in many different forms. Health care providers or plan members might submit claims for products and services that weren’t actually provided. In some cases, plan members might receive a service or product not covered by a benefit plan, then submit a claim for something that is.

Health care providers can be guilty of benefits fraud too. A provider may increase the cost of their service but offer a “free” product in return, or they may commit unbundling—claiming separately for procedures that are actually part of a single procedure.

Some other common cases of benefits fraud include

  • receiving spa treatments and claiming them as therapeutic massages,
  • receiving non-prescription sunglasses and claiming them as prescription glasses,
  • receiving cosmetic dental work and claiming it as regular dental work, and
  • receiving a service or product yourself but claiming it under another plan member’s name.

These are just some examples of benefits fraud and abuse, and the list is far longer than that. Plan members, health care providers or even third-party offenders can commit a variety of types of benefits fraud and abuse, and they can impact you whether you’re involved or not.