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Preventing Fraud and Abuse:
How You Can Help
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Of the more than $1 trillion Americans spend every year on health care, the Federal Government estimates that more than $100 billion—or, about 10 percent—is lost to fraud and abuse. Yet, in many cases, both can be prevented with your help.
What Constitutes Fraud and Abuse?
Fraud occurs when a person or organization intentionally deceives others to gain some sort of unauthorized benefits. Abuse occurs when a provider bills for services or supplies that are not medically necessary or do not meet professional standards.
Examples of fraudulent activities include:
- Falsifying claims, medical records or eligibility
- Misrepresenting the dates, frequency, duration or description of services rendered
- Misrepresenting who provided the services
- Submitting claims for services not rendered/used
Examples of abuse include:
- A pattern of claims for services not medically necessary
- A pattern of waiving cost-shares and/or deductibles
- Failure to maintain adequate medical or fi nancial records
- Improper billing practices
- Refusal to furnish or allow access to medical records
How You Can Help Stop Fraud and Abuse
Be sure to carefully review your explanations of benefits statements. If you suspect fraud or abuse, you can:
- Call 1-800-333-1620 to report your complaint
- Report it online
- Mail your complaint to:
Humana Military Healthcare Services, Inc.
Attn: Program Integrity
500 W. Main Street, 19th floor
Louisville, KY 40202
By working together to prevent fraud and abuse, and detecting incidents early, we can address them quickly, leading to more affordable health care for all TRICARE beneficiaries.
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