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Health Care Fraud & Abuse

How Health Insurance Fraud and Abuse Cost You Money

Health insurance fraud in the United States costs Americans an estimated $80 billion a year, or nearly $950 for each family (Source: Iowa Fraud Bureau):

  • The National Health Care Anti-Fraud Association estimates that at least 3% of the nation's annual health care outlay is lost to outright fraud.
  • According to the Administration on Aging, the United States Accounting Office estimates that $1 out of every $7 spent on Medicare is paid inappropriately due to error, fraud or abuse.
  • This results in higher taxes to support federal health care programs.
  • This results in higher private health insurance premiums.
What Constitutes Health Insurance Fraud and Abuse

Health insurance fraud occurs when someone intentionally submits, or causes someone else to submit, false or misleading information for the purpose of altering the amount of health care benefits paid. Health insurance abuse consists of any action, against an insurer, which results in an unfair gain to the claimant, or some other person or entity, that is inconsistent with acceptable business and/or medical practices (Source: Blue Cross Blue Shield Association).


Examples of health care insurance fraud and abuse include:

  • Adding a person not eligible for coverage to a Wellmark Blue Cross and Blue Shield contract.
  • Using an expired Wellmark ID card.
  • Loaning an ID card to someone not entitled to use it.
  • Inappropriate billing practices by a provider, including billing for non-payable services under payable codes or billing for services that were not rendered.
  • "Doctor shopping" for prescriptions or visiting various emergency rooms to obtain narcotic drugs. Prescription drugs now account for between 25 and 30 percent of all drug abuse, and ER visits for narcotic pain relief have jumped 163% since 1995.
What You Can Do to Help

Active identification of health care fraud and abuse, and appropriate action in response, is an expectation of every Wellmark employee and is a commitment of Wellmark's Compliance Program. Investigations of health care fraud and abuse allegations are conducted under the direction of Wellmark's Vice President Audit Services.


By taking these steps, you can help protect yourself and others from health insurance fraud and abuse:

  • Protect your health insurance card like you would a credit card. If your card is lost or stolen, contact Wellmark Customer Service immediately.
  • Closely examine your Explanation of Benefits (EOB) forms to ensure that all the information is accurate and that you received the services reported.
  • Beware of free medical exams, co-payment waivers, or advertisements stating "covered by insurance."
  • Contact Wellmark's Special Investigations Unit to report possible fraud and abuse if you suspect health insurance fraud.
How to Report a Case of Suspected Fraud

Contact Wellmark's Special Investigations Unit by using one of these methods:

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