Fraud and Abuse
What is health care fraud?
Health care fraud is the deliberate submission of false information to gain undeserved payment on a claim.
What is abuse?
Abuse involves a questionable practice inconsistent with accepted medical or business policies. While not an intentional misrepresentation, it may result in unnecessary costs.
Who can commit fraud or abuse?
Anyone involved in health care:
- Someone posing as any one of these individuals
What are the warning signs?
Items or services on your Explanation of Benefits (EOB) which:
- You didn't receive.
- Are different from those you received.
- Are unnecessary, inappropriate, or of questionable medical benefit.
- Are billed under a different name than the individual who provided the service.
- Offers "free" items or services to you, but then bills them to WPS.
- Any person (other than a covered dependent) who uses your insurance identification card to obtain medical care.
- Someone who misrepresents information on a health insurance application or form.
- Submits falsified claims with stolen/purchased physician or patient identification information.
How does fraud and abuse affect you?
Fraudulent and abusive claims can affect your health care history. If a claim is filed for a service you didn't receive, this could:
- Affect your future ability to obtain life or health insurance.
- Increase insurance premiums.
- Affect the health care received from other providers.
How can you help stop fraud and abuse?
Know the warning signs:
- Read your EOB and make sure all of the services listed were received.
- Never give your health insurance number to anyone over the phone.
- Question advertisements, telephone calls or promotions that offer free tests, treatment or services - especially when they request your insurance information and ID card.
How can I report fraud or abuse?
- Use our online form.
- Email us.
- Call our toll-free fraud and abuse hotline: 1-888-766-4681 (TTY:711).
Where can I get more information?
Visit the websites below: