Fraud, Waste & Abuse

ATRIO Health Plans is committed to detecting, preventing, and correcting healthcare fraud, waste, and abuse because it affects everyone. ATRIO wants to make sure you know what it is, how to spot it, and how to help us prevent it.

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Overview

The United States spends a substantial amount of money on health care fraud. Resources estimate that the financial losses due to health care fraud are in the tens of billions of dollars each year. A conservative estimate is 3% of total health care expenditures, while some government and law enforcement agencies place the loss as high as 10% of our annual health outlay, which could mean more than $300 billion.

In 2023 the U.S. Justice Department recovered more than $2.68 billion dollars from lawsuits involving healthcare fraud and false claims.

https://www.justice.gov/opa/pr/false-claims-act-settlements-and-judgments-exceed-268-billion-fiscal-year-2023#:~:text=Of%20the%20more%20than%20$2.68,in%20government%20contracts%20and%20grants

The department’s $2.2 billion recovery in fiscal year 2022 was the lowest since 2008 and marked a sharp decline from 2021 when recoveries exceeded $5.6 billion, the second largest in a single year since tracking began in 1986. 2021 marked the 14^th straight year of increasing recoveries.

Due to the pandemic, the recoveries in fiscal year 2022 also reflected the department’s focus on new enforcement priorities, including fraud in pandemic relief programs and alleged violations of cybersecurity requirements in government contracts and grants.

https://www.winston.com/en/blogs-and-podcasts/government-program-fraud-false-claims-act-and-qui-tam-litigation-playbook/dojs-2022-fca-recoveries-announcement-reveals-one-of-the-smallest-hauls-in-recent-years-but-indicates-a-different-2023-outlook#:~:text=That%20said%2C%20fiscal%20year%202022,single%20year%20in%20DOJ%20history.

There are several ways health care practitioners, pharmacies, and members can commit fraud. A few examples include:

Practitioners:

• A practitioner submits a bill for services that were not delivered.
• A practitioner bills for a higher level of service than what was delivered.
• A practitioner bills for a non-covered service as a covered benefit.

Pharmacy:

• An existing prescription is altered to increase the quantity or number of refills.
• A pharmacist provides the incorrect number of refills prescribed by the provider.

Members:

• Allowing someone who is not covered use their ATRIO Member ID card to obtain health care services or prescriptions.
• Altering or forging a prescription.

¹ https://www.justice.gov/usao/resources/journal-of-federal-law-and-practiceLearn

 

To learn more, go to:

• Medicare Fraud & Abuse: Prevent, Detect, Report
• Help fight Medicare fraud

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Keeping Watch

When it comes to your health insurance, if something doesn’t feel right, report it to us. Do not be concerned about whether it is health insurance fraud, waste, or abuse. Report your concerns to the ATRIO Customer Service Department. The ATRIO Compliance Department will investigate and make the proper determination.

• Carefully read the Explanation of Benefits (EOB) you receive.
• Take note if you seem to be paying unusually high charges for regular services.
• Understand what services your benefits provide for.
• Watch for phone scams offering free medical services or supplies and take note of the caller’s phone number.

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Definitions

Health care fraud: Includes health insurance fraud, drug fraud, and medical fraud. Health insurance fraud occurs when a company or an individual defrauds ATRIO, an insurer or government health care program, such as Medicare (United States) or equivalent State programs. The manner in which this is done varies, and persons engaging in fraud are always seeking new ways to circumvent the law.

In other words:

Fraud: Knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program; or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program.

Waste: Overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.

Abuse: Includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and or/intentionally misrepresented facts to obtain payment.

Identifying Fraudulent Emails

The purpose of phishing emails is to steal your identity or personal information. These emails may imitate the logos, style and language used by reputable companies. Protect yourself from these scams by learning to identify them.

Look for the following:

• Generic greetings or mistakes in the greeting.
• A false sense of urgency. Many phishing emails threaten you to act immediately to avoid losing access to your account or cancelling your contract.
• Misspellings and bad grammar.
• Pop-up boxes in an email are not secure. If a pop-up box appears simply by opening an email, do not enter personal information into it.
• Links in the email that go to web sites other than ATRIO sites.

If you receive a suspicious email related to your health insurance, services or supplies that you would like to report, please call 1-877-672-8620 (TTY 711).

Phone Scams: Don’t be a victim

If you receive a phone call from someone offering free genetic testing, free orthotic braces, free foot spas, or anything else, don’t be a victim.

Try to capture the phone number the call is coming from, using either caller ID or the recent call history on your cell phone.

Do not give ANY personal information or answer any of their questions.

Try to obtain:

• The name of the company.
• Whether they say they are representing Medicare.
• The state they are calling from.
• Date and Time of the call.
• The caller ID number

Any other information may be useful for an investigation by ATRIO. Report the call to the ATRIO Customer Service department at 1-877-672-8620 (TTY 711).

You May Also Report Unwanted Calls to the Federal Communications Commission (FCC).

File an informal Consumer Complaint with the Federal Communications Commission (FCC)

FCC Consumer Complaint Center

Phone: 1-888-225-5322TTY: 1-888-835-5322
Videophone: 1-844-432-2275
Fax: 1-866-418-0232

Para presentar una queja en español, llamar al: 888-CALL-FCC (888-225-5322).

Tips to Prevent Fraud, Waste, and Abuse

1. Protect your ATRIO ID number and your Social Security number. Protect your ATRIO health ID card like it's a credit card.
2. Encourage the healthcare providers you see to request photo identification to avoid identity theft.
3. Remember that nothing is ever "free." Don't accept offers of money or gifts for free medical care. If the care is truly free, then the provider should not ask for your insurance information. Often services touted as "free" are later billed to the insurance company and may or may not be covered.
4. Be wary of providers who tell you that the item or service isn't usually covered, but they "know how to bill ATRIO so the claim will pay." If they know the service is not covered then they should not submit the claim to ATRIO.
5. Don't let anyone persuade you to see a doctor for care or services you don't need. Ask your provider why you need testing before you agree to be tested. Ask your doctor if the tests are covered by your insurance.
6. Ask your doctor if he is referring your lab work to in network laboratories. You may be charged a higher copayment and/or deductible for out of network providers.
7. Don't be influenced by certain media advertising about your health. Many television and radio ads don't have your best interests at heart.
8. Ask questions. You have a right to know everything about your medical care including the costs billed to your insurance company.
9. Use a calendar to record all of your doctor's appointments and what tests or x-rays you get. Then carefully check your Explanation of Benefits (EOB) either online or in the mail, to make sure you received each service listed and that all the details are correct. If you spend time in a hospital, make sure the admission date, discharge date, and diagnosis on your bill are correct.
10. Report suspected instances of fraud by completing the online form or calling ATRIO Customer Service at 1-877-672-8620 (TTY 711). You can remain anonymous if you'd like.

Report Suspected Fraud or Abuse

Please report suspected health insurance fraud, waste, or abuse to ATRIO’s Medicare Compliance Team by clicking the link below.

Report Suspected Fraud or Abuse

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Fraud, Waste, and Abuse Training

A new Combating Medicare Parts C and D Fraud, Waste, and Abuse (FWA) Web-Based Training course is available through the Medicare Learning Network®. Learn about:

• FWA in the Medicare Program.
• The major laws and regulations pertaining to FWA.
• Potential consequences and penalties associated with violations.
• Methods of preventing FWA.
• How to report FWA.
• How to correct FWA.

Combating Medicare Parts C & D Fraud, Waste, and Abuse

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Office of Inspector General

You may report suspected fraud, waste, or abuse directly to the OIG Hotline at: 1-800-447-8477 TTY / 1-800-377-4950 or go to https://oig.hhs.gov/about-oig/about-us/index.asp

View recent fraud alerts or schemes published by the OIG: Consumer Alerts Webpage