To prevent fraud and abuse
Understanding my explanation of benefits (EOB)
Always review your Explanations of Benefits (EOBs) and medical bills to ensure that the services billed were actually performed by the provider indicated and on the date specified. You can learn more about the information contained within your EOB visiting the PGBA Web Site.
Should you have a question about your bill, contact the doctor who provided the services, or the PGBA Claims Line at 1-800-403-3950.
Guidelines to help prevent fraud and abuse
- Keep track of every bill received or paid by your insurance provider to make sure that you are not billed more than once for the same service.
- Do not be afraid to question your health care provider about the necessity of each procedure that is being ordered for you, especially if it seems excessive.
- Do not accept a discount of medical payments or the waiver of your co-payment unless you are assured that the discounted amount is reflected on the billing for your health care provider.
What does fraud and abuse mean to you?
Why program integrity?
Most health care providers subscribe to the highest code of ethical standards. However, as in any large population, some individuals intentionally seek to defraud the system. In fact, estimates indicate that between 7% to 10% of the $2.7 trillion annual health care expenditures in the United States are fraudulent.
*By actively coordinating with government officials and other insurers, our fraud investigators work to identify and investigate every individual attempting to defraud or seriously jeopardize the quality of patient care. Why? Because crimes involving health care fraud lead to:
- Higher taxes
- Higher cost shares for medical services
- Do The potential for false medical histories in patients' records
Humana Government Business formed the Program Integrity department to help combat this fraud and other attempted abuses committed within the TRICARE Health program. Our fraud investigators are committed to the prevention, detection, and investigation of every alleged fraud and abuse case.
Did you know?
*Denotes information referenced from the FBI web site.
What is health care fraud?
- Health care expenditures in the U.S. are approximately $2.7 trillion annually?
- This is a very alluring target for those who would choose to perpetrate fraud schemes!
- Every dollar lost to health care fraud is one dollar less for national defense?
- Health care fraud is defined as intentionally misrepresenting a service or supply in order to receive a higher benefit?
- The crime of health care fraud is the second priority of the United States Department of Justice?
Health care fraud is defined as: "An intentional act of misrepresentation or deception that results in a higher benefit to the beneficiary, the provider, or some other entity."
What is abuse?
Any practice that is inconsistent with accepted and sound, fiscal business, or any professional practice which results in a TRICARE claim cost for TRICARE payment for services or supplies that is: (1) not within the concepts of medically necessary and appropriate care or (2) fails to meet professionally recognized standards for health care providers.
Examples of fraudulent and abusive medical practices include:
- Charging more than once for the same service (double billing).
- Charging for services never performed or medical equipment/supplies never ordered.
- Performing inappropriate or unnecessary services.
- Offers of free services or medical equipment in exchange for your policy number.
- Providing lower cost or used equipment while billing TRICARE for higher cost or new equipment.
- A supplier completing a certificate of medical necessity form for a physician.
- Awareness of an ineligible beneficiary on someone's plan, i.e. girlfriend listed as a spouse.
- A provider solicits a "free" consultation or service, which is then billed to TRICARE.
- Someone offering you an incentive to sell your insurance information, i.e. policy numbers.
- A provider offers to conceal non-covered services by using a different allowable description.