Frequently asked questions
Fraud is purposely being dishonest or misrepresenting facts to get something of value. It’s when a provider, member or entity is purposely dishonest or misrepresents facts knowing it will result in an inappropriate gain or benefit.
Waste is using more services than you need or practices that, directly or indirectly, result in unnecessary costs to the health care system. It is not generally caused by criminal actions, but by overusing resources.
Abuse is an action that may result in unnecessary costs to the health care system. It’s when a person or entity has not knowingly or purposely misrepresented facts but receives a payment that they have no legal reason to get.
Health care fraud and abuse happens in many places and situations. Examples can be provider, pharmacy, member or patient fraud. It’s important to be aware of suspicious situations and be ready to report concerns. Take a look at the different types of fraud and abuse (in the next question) so you’ll have a better idea if a situation should be reported.
Here are some examples to help you know what is considered fraud and abuse.
Examples of potential PROVIDER fraud and abuse include:
- Submitting bills or claims for treatment or services that were never provided
- Claiming a false date of service to correspond with a member’s coverage period
- Billing for non-covered services using incorrect codes to attempt to have services covered
Examples of potential PHARMACY fraud and abuse include:
- Incorrect pharmacy billing
- Bills for medication that was never dispensed.
- Bills for brand name drugs, but dispensed generic drugs.
- Prescription drug shorting
- Less than the prescribed quantity is intentionally provided and the patient is not informed
- Prescription forging or altering – done without the prescriber’s permission to increase the quantity of tablets or number of refills
Member or patient
Examples of potential MEMBER OR PATIENT fraud and abuse include:
- Submitting false claims.
- Prescription stockpiling and unlawful sales of excessive services and goods for resale.
- Concealing information about additional coverage in order to lower out-of-pocket payments, or receiving inappropriate reimbursement from multiple plans.
- Identity theft.
- Doctor shopping.
- Multiple providers are seen in an attempt to obtain multiple prescriptions. Usually includes deception and can be driven by addiction, drug diversion for profit or both.
Yes. There are two ways to submit a report without identifying yourself.
- Contact the UnitedHealthcare Fraud Hotline number at 1-844-359-7736 and say that you would like to make an anonymous report.
- Complete an online form here.
When you report health care fraud, any information you provide about yourself will stay confidential. That means that even if you give your name in the report, the health care provider(s) would not know that you reported them. However, you may also enter your complaint anonymously.
You can call the the number on the back of your health plan ID card or contact the Member Services Call Center at 1-866-633-2446. They can help with questions about your health plan, including explaining bills, claims and coverage, helping you find network providers, like doctors, clinics or hospitals, or other questions and concerns.