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Medicare Fraud

The Scope of Fraud, Waste and Abuse on our Healthcare System

The National Healthcare Anti-fraud Association (NHCAA) cites an average of 3% (at the low end) and 10% (at the high end) of healthcare spending is lost due to fraud. That's between $67 Billion and $230 Billion lost each year to fraud, waste or abuse. That estimates to between $184 million and $630 million dollar loss per day, and this number is expected to increase every year as healthcare costs rise.* Healthcare fraud is believed to be the second largest white-collar crime in the United States. It is often mistaken for a victimless crime, but it affects everyone. Fraud causes insurance premiums to rise, and victims may be put through unnecessary or unsafe procedures. Victims of identity theft may find their insurance information used to submit false claims. This is a staggering cost, and we are committed to battling these unnecessary expenditures every step of the way.

Our Commitment

Universal American is committed to fighting healthcare fraud, waste, and abuse.

We have a dedicated Special Investigations Unit (SIU) whose mission is to protect our employees, members, providers, first tier, downstream, and related entities, and the Medicare Trust Fund by administering an effective plan to prevent and detect fraud, waste, and abuse.

The SIU works diligently to investigate all allegations, correct known offenses, recover lost funds, and partner with federal and state agencies to prosecute violators to the fullest extent of the law.

Contact the SIU

Examples of Healthcare Fraud

  • A healthcare provider bills for medical services, supplies or items that were not provided
  • A healthcare provider bills for a more expensive service or procedure than what was actually provided or performed
  • A healthcare provider performs medically unnecessary services to obtain the insurance payment
  • A healthcare provider misrepresents a non-covered service as medically necessary to obtain the insurance payment
  • A healthcare provider or pharmacy charging a beneficiary a price over the copay amount
  • A healthcare provider or pharmacy waives the patient’s copay amount and overbills the insurance plan to recoup the cost
  • A pharmacy bills for prescriptions that were not dispensed
  • A pharmacy dispenses a generic drug, but bills for a brand name drug
  • Prescription drug shorting by the pharmacy (i.e., billing for 60 tablets, but dispensing 30)
  • A pharmacy adds unauthorized refills to prescriptions
  • Drug diversion
  • A pharmacy, beneficiary or policy holder forges or alters a prescription
  • A beneficiary or policyholder misrepresents their personal information such as identity, eligibility, or medical condition in order to illegally receive a benefit
  • Someone steals or purchases a beneficiary's or policyholder's personal information to submit false or phantom claims to obtain the insurance benefit
  • A beneficiary or policyholder allows a third party to use their benefit information to obtain medication and/or medical services
  • A third party pretends to represent Medicare, the Social Security Administration or an insurance plan for the purpose of obtaining personal and/or financial information

Protect Yourself Against Fraud

  • Treat your Medicare card, Social Security card, and insurance ID card like you would your credit card. It could be very costly if it fell into the wrong hands
  • Do not give out personal information over the phone or through mail unless you have initiated the contact
  • Be cautious of providers who offer "free" testing or screening but require your Medicare and/or insurance card first. Thieves use this scam to get personal information then use it to commit fraud or sell it
  • Avoid utilizing a healthcare provider or pharmacy who tells you that the item or service is not usually covered, but they know how to bill Medicare to get it paid
  • Review your Explanation of Benefits (EOB) promptly. Look for:
    • Charges for a service, drug, equipment and/or supplies you did not get
    • Billing for the same service, drug, equipment and/or supplies twice
    • Services that were not ordered by the Doctor
  • Report fraud. Contact the Special Investigations Unit if you suspect fraud, waste or abuse

Help Fight Fraud

If you suspect someone of committing insurance fraud against Universal American or think you may be a victim, please report the suspicious activity to the Special Investigations Unit (SIU) at:

  • Fraud, Waste, and Abuse Hotline: 1-800-388-1563
  • Email: fraud@UniversalAmerican.com
  • In writing:

    Universal American
    Attn: FWA Department
    Special Investigation Unit
    P.O. Box 27869
    Houston, Texas 77274

All communications are confidential and may be anonymous.

For more information about insurance fraud, please visit the following Web sites:

www.insurancefraud.org (by clicking on this link you will be leaving our Web site)
www.stopmedicarefraud.gov/ (by clicking on this link you will be leaving our Web site)
oig.ssa.gov/report-fraud-waste-or-abuse (by clicking on this link you will be leaving our Web site)

*The National Healthcare Anti-fraud Association (NHCAA). "Anti-Fraud Resource, Consumer Info & Action." Available at: http://www.nhcaa.org/resources/health-care-anti-fraud-resources/consumer-info-action.aspx (by clicking on this link you will be leaving our Web site)