GEHA is committed to fighting health care fraud, waste, abuse and helping you get the best value for your medical and dental care. We need your help in this fight.
Please report suspected health care fraud, waste or abuse – including identity theft – to the following phone number or website:
Available 24 hours a day, 365 days a year
Translators are available
What is health care a fraud, waste and abuse?
Health care fraud is a crime. Fraud is generally defined as knowingly and willfully executing, or attempt to execute, a scheme or deceit to defraud a health care or dental insurance or benefit program, or to obtain by fraudulent means any benefit or payment from the program.
Examples of provider health care fraud include:
- billing for services that were never rendered,
- misrepresenting who provided the services,
- altering claim forms, electronic claim records or medical documentation, and
- falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that are not medically necessary.
Examples of consumer health care fraud include:
- filing claims for services or medications not received,
- forging or altering bills or receipts,
- using someone else’s coverage or insurance card, and
- including ineligible dependents on your plan.
Waste is over-utilization of services or other practices that results in unnecessary costs to the health care system. It is usually not caused by criminally negligent actions, but the misuse of resources.
Examples of waste include:
- performing a large number of laboratory tests on a patient when the standard of care indicates that only a few tests were sufficient for treatment and/or diagnosis, and
- medication and prescription refill errors.
Abuse involves payment for items or services when there is no legal entitlement to that payment and the individual or provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
Examples of abuse include:
- misusing procedure or diagnosis codes on the claim (i.e. the way the service is coded on the claim does not comply with national or local coding guidelines or is not billed as rendered),
- waiving patient co-pays, coinsurance or deductibles and over-billing the FEHB program carrier, and
- billing for items or services that should not be paid for by the FEHB program such as never events.
Help avoid and prevent health care fraud
Here are some easy ways you can protect yourself from health care fraud, and keep medical and dental costs down for everyone .
- Protect your health insurance ID card like a credit card. In the wrong hands, a health insurance card is a license to steal. Don't give out policy numbers to door-to-door salespeople, telephone solicitors or over the Internet. Be careful about disclosing your insurance information and if you lose your insurance ID card, report it to GEHA immediately.
- Be informed. Be informed about the health care services you receive, keep good records of your medical care and closely review all medical bills you receive.
- Read your policy and benefits statements. Read your policy, Explanation of Benefits statements and any paperwork you receive from your insurance company. Make sure you actually received the treatments for which your insurance was charged and question suspicious expenses. Are the dates of service documented on the forms correct? Were the services identified and billed for actually performed?
- Beware of "free" offers. Is it too good to be true? Offers of free health care services, tests or treatments are often fraud schemes designed to bill you and your insurance company illegally for thousands of dollars of treatments you never received.
- Report fraud. Call GEHA’s Ethics Hotline immediately if you suspect you may be a victim of health insurance fraud.
GEHA is working to minimize health care fraud
GEHA’s Special Investigations team is responsible for minimizing GEHA’s risk to health care fraud. The Special Investigations team partners with GEHA’s Customer Care, Claims Operations, Data Analytics Center of Excellence and others to help identify suspicious medical and dental claims, stop payments to fraudulent providers and assist with ensuring wrongdoers are held accountable for their actions.