Examples of Fraud & Abuse

Some examples of member and provider fraud and abuse are provided as follows:

Member Fraud & Abuse

  • Eligibility Determination Issues that include the following items:
    • Resource Misrepresentation (Transfer / Hiding )
    • Residency
    • Household Composition
    • Citizenship Status
    • Unreported Income
    • Misrepresentation of Medical Condition
    • Failure to Report Third Party Liability (TPL)

Provider Fraud & Abuse

  • Falsifying Claims/Encounters that include the following items:
    • Alteration of a claim
    • Incorrect coding
    • Double billing
    • False data submitted
  • Administrative/Financial actions that include the following items:
    • Kickbacks
    • Falsifying credentials
    • Fraudulent enrollment practices
    • Fraudulent Third Party Liability (TPL) Reporting
    • Fraudulent Recoupment Practices
  • Falsifying Services that include the following items:
    • Billing for Services / Supplies Not Provided
    • Misrepresentation of Services / Supplies
    • Substitution of Services