Fraud, waste, and abuse

Everyone is concerned about rising health care costs and many assume there’s nothing they can do about it. However, estimates are that up to 3 percent of health care costs are wasted by overstated, double-billed, or otherwise fraudulent charges. We all pay for these excesses. Valley Health Plan (VHP) is committed to the prevention, detection, and reporting of health care fraud, waste, and abuse. You, our health plan members, are a vital part of helping us address this problem. In the process, you are protecting yourself from unnecessary higher costs and potentially more serious concerns, such as identity theft.

We encourage members to notify VHP of any suspicious activity you might encounter while receiving care from one of our practitioners or providers. All complaints regarding fraud will be investigated. This will allow VHP to take the necessary actions to protect members from unlawful activities.

Defining health care fraud, waste, and abuse

Fraud is knowingly and willfully attempting to falsely obtain money from any health care benefit program. Fraud is distinguished from abuse in that there is clear evidence that the acts were committed knowingly, willfully, and intentionally or with reckless disregard.

Waste is health care spending that can be eliminated without reducing the quality of care, such as overuse (prescribing too many antibiotics), underuse, and ineffective use of treatments or medications. It is also the inefficiency in redundant testing, delays in treatment, and making processes unnecessarily complex.

Abuse is defined as improper actions or billing practices that create unnecessary costs.

A $60 billion problem

The United States spends more than $2 trillion annually on health care. Conservative estimates are that 3 percent or more than $60 billion each year is lost to fraud, waste, and abuse.

While the vast majority of physicians and other health care providers are honest and legitimate, it is the few that aren’t that cost all of us money and negatively affect health care. Even honest providers can make billing mistakes; it’s up to everyone to help address this issue.

What fraud, waste, and abuse mean to you

• The costs affect patients, taxpayers, and the government through higher health care costs, insurance premiums, and taxes.
• Your medical record could contain incorrect information about your medical history.
• Falsely billed procedures as a result of medical identity theft and fraud create incorrect information in your medical record, which can make it difficult for you to get insurance coverage in the future.
• In extreme cases, unnecessary or unsafe procedures could cause injury or death.

Spotting fraud, waste, and abuse

• An individual or organization calls you, saying they represent Valley Health Plan (VHP), Medicare, or other government entity and asks you for insurance information, Social Security number, bank account number, credit card number, or other personal information.
• Someone asks you to sell the use of your medical insurance card or prescription drug card.
• Someone asks you to get drugs for them by using your prescription drug card.
• You were encouraged to sign up for another plan and disenroll from your current plan with an offer of cash or a gift worth more than $15.
• Your pharmacy did not give you all the drugs that should have been covered (your doctor ordered 30 and you were given 25) or you were charged for drugs you did not receive.
•  You received a different drug than your doctor ordered, not including generic substitutes.
• You believe you were charged more than once for your copay or deductible.
•  You are billed for the services of a provider that you did not see.
• You are charged for services you did not receive or you are billed for services on dates that you were not with the provider.

These examples are only a small list of possible fraud, waste, and abuse situations. Some of these could be honest mistakes by your providers. If you are uncertain about whether a situation was fraud, waste, or abuse, always feel free to call Valley Health Plan (VHP).

Help stop fraud, waste, and abuse

Read

By reading your benefits information or policy you will know what services are supposed to be covered. By reading your Summary of Benefits and Coverage (SBC) that are mailed to you after you have received services, you will know if the date of service is correct (did you have services on that date?), if the service itself was performed, or if any services appear that does not seem correct. If you have questions about the information on the SBC, you should contact your provider’s office and ask for an explanation, it may be a simple billing error. If the provider does not resolve the issue, contact Valley Health Plan (VHP) using the information below.

Be aware

• “Free” offers of services or equipment are often fraud schemes designed to bill you and your insurance company illegally for treatments you will not receive.
• Offers of “knowing how to bill” to get an uncovered service or item paid for, is likely not legitimate.
•  Allowing others to use your medical insurance card is fraud and you can be prosecuted.

Protect yourself

• Treat your health insurance card like it was your credit card. Report a lost or stolen card immediately.
• Do not give out your health insurance card or policy numbers to door-to-door salespeople or phone solicitors.

Report it

• Make a report if you receive a claim or notice of a prescription that does not look right, call Member Services and/or your Provider.
• Bring it to our attention if you believe you’ve experienced or are aware of any fraud (waste or abuse of VHP health care resources), please contact VHP Member Services at 1 (888) 421-8444 (toll-free), Monday - Friday, 9:00 am to 5:00 pm for assistance.​​​​​​