Red Flags of Fraud

How can you assist us in safeguarding your health care dollars? Watch out for red flags that could indicate potential fraud. If you suspect potential health care fraud, please let us know.

Some of the factors that could indicate potential fraud include:

  • Resubmitting denied claims (e.g. billing for the same services using a different procedure code after the first procedure was denied)
  • Billing for services that aren't covered by coding the service as a procedure that is a covered service
  • Altering claims or patient record (e.g. date inserted, items handwritten when the rest of claim isn't)
  • Misusing or misspelling medical terms
  • Listing services as rendered in another state or on a holiday or weekend
  • Submitting multiple billings for the same service
  • Billing for services that haven't been rendered
  • Billing for an amount that doesn't correspond to the services rendered
  • Altering receipts or claims
  • Using the same last name for both the provider and the patient (most benefits list an exclusion of providers billing for the treatment of family members)
  • Circumventing benefit exclusions (patient exhausts all physical therapy benefits and the provider continues to render physical therapy services and bills them as an office visit or submits the physical therapy services under the spouse's name)
  • Submitting high dollar claims (e.g. charges for the service being billed are out of the ordinary)