Fraud and Abuse Policy
What is healthcare fraud?
The following definitions and information will be helpful in understanding how the regulatory agencies interpret fraud and abuse.
Fraud – when a person or group of people attempt to do something to cheat any healthcare plan which causes the person or group of people to benefit from their actions.
Abuse – when something is done differently than is considered accepted practice.
Intent - the state of mind in which an act is done. Intent is what makes a person do something. A person’s intent can be the difference between fraud and abuse.
Waste - the overutilization of services or practices that directly or indirectly result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.
Examples of Provider Fraud:
- Billing for services not actually performed.
- Upcoding - billing for a more costly service than the service actually performed.
- Unbundling – billing each step of a procedure as if it were separate instead of billing it under the procedure as a whole.
- Falsifying a diagnosis to justify test, surgeries or other procedures that are not medically necessary.
- Billing for services under a provider that did not actually perform services.
- Waiving copays or deductibles.
- Accepting kickbacks for member referrals.
Examples of Member Fraud:
- Using someone else’s insurance card.
- Providing false statements on an enrollment application such as dependent information to obtain health coverage.
- Using SummaCare as your primary insurance when another insurance carrier is your primary coverage.
- Using a false home address to obtain coverage when your primary address is out of the service area.
Examples of Employer Fraud:
- Falsifying an employee hire date to modify the date of health care coverage.
- Falsifying an employee termination date in order to eliminate premium payments.
Help Fight Fraud & Abuse
1. Read your EOB (Explanation of Benefits) carefully.
This is your notification that SummaCare has been billed for services performed under your benefit plan. A few items to look for:
- Providers who did not see or treat you
- Services that you did not receive
- Incorrect dates of service.
Errors that you identify on your EOB may not prove to be fraudulent situations. However, all reports of discrepancies are thoroughly investigated to determine if fraudulent activity does exist.
2. Report all possible cases of fraud and abuse.
Call or write us to report fraud or abuse. Call the SummaCare Compliance Hotline at 800-361-3908 or 330-996-8821 and leave a message that includes:
- The reason you believe a fraudulent or abusive situation has occurred
- Information regarding the situation in question
- The name of the individual, provider or group that may have committed fraud or abuse
- The date(s) the situation occurred
- Any other information you have that may help with the investigation
- You may leave your name and number or choose to remain anonymous
Write to us at: SummaCare Compliance Department F&A, P.O. Box 3620, Akron, Ohio 44309-3620
Download and complete Suspected Violations Report.
Last Updated: 03/16/2016