Health care fraud is committed when false or misleading information is submitted to improperly maximize the amount of health care benefits paid. It is a crime. Fraud comes in many forms — from contriving complex billing schemes to using someone else’s ID card to obtain medical services.

The cost of fraud affects everyone. The U.S. General Accounting Office estimates that health care fraud costs consumers approximately $35 to $60 billion dollars annually. For employers, fraud increases the cost of providing benefits and the overall cost of doing business. This translates into higher premiums and out-of-pocket costs for employees.

Examples of Fraud

Most health care providers and consumers are honest and ethical; only a small portion engage in fraudulent acts. The U.S. Chamber of Commerce estimates that 3 to 10 percent of health care cost is attributed to fraud annually.

What constitutes fraud?

Fraud includes:

  • billing for services not provided;
  • falsifying medical diagnoses or procedures to maximize payments;
  • misrepresenting dates, descriptions of services, or identities of plan members or providers;
  • billing for a more costly service than the one that was provided or billing for duplicate services;
  • accepting bribes for patient referrals;
  • billing for non-covered services as covered items (e.g. cosmetic surgery);
  • providing false employer group and/or group membership information;
  • prescription fraud;
  • rent-a-patient fraud schemes.

What to look for:

  • mistakes on your Explanation of Benefits (EOB) such as payments made for services that were not performed or names and dates that don’t agree with your records;
  • individuals using an expired health insurance ID card;
  • an individual who “lends” his or her card to someone who is not entitled to use it;
  • drug diversion, over-utilization, or substitution of brand name drugs for generic.

Report Fraud

If you suspect health care fraud against Inter-County, we urge you to report it. All reports are confidential. You are not required to provide your name, address, or other identifying information.
You have three options for submitting your report:

  • submit a Fraud and Abuse Tip Referral form electronically;
  • call the confidential anti-fraud hotline toll-free at 1-866-282-2707;
  • mail a report. Write a description of your complaint, enclose copies of any supporting documentation, and mail it to:

Corporate & Financial Investigations Department
1901 Market Street, 15th Floor
Philadelphia, PA 19103

Health care fraud is a violation of state and/or federal law. Under federal law it is a felony offense (18 USC 1347), punishable by a fine of up to $250,000 and/or up to 10 years imprisonment. If the violation results in serious bodily injury, up to a 20-year prison term is possible.

Request a Proposal

Contact an Inter-County sales representative for more information or to request a proposal.