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