Fraud, Waste and Abuse Program

What is health care/insurance fraud?

Fraud is the intentional misrepresentation of a material fact that is relied upon by the victim, which results in the loss of property, usually monetary. This can include payment for health care services induced by fraud.

Examples of consumer fraud include:

  • Fraudulent omission or misrepresentation of medical information or history on the application
  • Fraudulent coverage of dependents
  • Fraudulent submission of claims
  • Altering prescriptions
  • Using another Member's card to obtain health care services
Examples of provider fraud include:

  • Falsifying recipient identities
  • Padding, or overstating health care charges
  • Upcoding, or charging for similar but higher priced services
  • Billing for services that were not provided
  • Asking for, offering, or accepting kickbacks
  • Performing non-covered services but billing for covered services

What is health care abuse?

Health care abuse usually means any activity that unjustly robs the health care system but does not constitute fraud. Health Plans like Rocky Mountain Health Plans (RMHP) and programs like Medicare, Medicaid and Child Health Plan Plus (CHP+) are all part of the health care system.  For example, a provider may obtain payment for health care services to which he/she is not entitled, but there is not the intent to deceive as there is with fraud.  This might include performing unnecessary services or poor billing practices.

What is not health care/insurance fraud or abuse?

General complaints or unhappiness with a provider or RMHP are not examples of fraud or abuse. See how to handle these kinds of matters by reading your Evidence of Coverage or Health Benefits Contract.

Learn how to report health care or Insurance Fraud or abuse.

Learn about required fraud and abuse training.