What is health care fraud and abuse?

  • Fraud is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment or benefit. The attempt itself is fraud, regardless of whether it is successful.
  • Abuse typically involves incidents or practices of providers that are inconsistent with accepted medical, business, or fiscal practices. These practices may, directly or indirectly, result in unnecessary costs, improper payments, or payments for services that fail to meet professionally recognized standards of care, or that are medically unnecessary.

Examples of health care fraud and abuse

  • Billed services not performed by a provider of care
  • Intentionally misrepresenting facts regarding the payment of benefits
  • Routinely waiving co-payments or deductibles
  • Billing for medically unnecessary items or services
  • “Unbundling” claims, or separate billing procedures instead of using a more appropriate global billing procedure
  • Upcoding claims, or billing at a higher rate than is appropriate for the item or service provided
  • Misrepresenting facts affecting eligibility for benefits, such as: employment status, health history, marital or student status, identity

Tips to help detect and prevent health care fraud and abuse

  • Review your Explanation of Benefits (EOB) and compare to the services billed by your provider of care. If there is a difference between your EOB and medical bill, contact MHBP.
  • Protect your health insurance information and do not share your health insurance plan card with anyone other than an authorized health care provider or your insurance plan
  • Be suspicious of free medical services that require your insurance information.
  • Inform us of any provider of care that routinely waives your copayments or deductibles
  • For more tips on identifying, preventing and reporting fraud visit the OPM website.

Reporting suspected health care fraud and abuse

Call our Special Investigations Unit (SIU) dedicated hotline to report suspected fraud and abuse activities at 1-800-338-6361 (TTY: 411) and select option 2. Simply leave a message and it will be reviewed promptly. You may also contact our 24 hours, 7 days a week customer service line at 1-800-410-7778 (TTY: 411) to make a report (except major holidays). If we do not resolve the issue you may call the OPM/OIG health care fraud hotline at 1-202-418-3300.

For more information on health care fraud and abuse, refer to the official Plan brochure.

Fraud and abuse websites

Visit the U.S. Office of Personnel Management/Office of the Inspector General website

Visit the National Health Care Anti-Fraud Association website

Visit the Coalition Against Insurance Fraud website

Visit Stop Medicare Fraud website

OPM Cybersecurity Incidents

If you were subject to the data breaches of the U.S. Office of Personnel Management and its contractor, and you experienced an out-of-pocket loss after the breaches, you could be eligible for a payment from a class action settlement.

The Settlement Agreement and more information on the lawsuit and your rights are available at www.OPMDataBreach.com or by calling toll-free 1-855-917-3567.