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What is Health Insurance Fraud, Waste 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)

Here are some examples:

  • 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% of all drug abuse, and ER visits for narcotic pain relief have jumped 163% since 1995.

How You Can Help

Take these steps to help protect yourself and others:

  • Protect your health insurance card like you would a credit card. If your card is lost or stolen, contact Wellmark Customer Service immediately at 800-524-9242.
  • 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, copayment 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.

Active identification of health care fraud and abuse, and appropriate action in response, is a commitment of Wellmark's Compliance Program and an expectation of every Wellmark employee.

How to Report a Case of Suspected Fraud

Contact Wellmark's Special Investigations Unit by:

All referrals are confidential.