Health Care Fraud 

Health care fraud can be committed by medical providers, patients, and others who intentionally deceive the health care system to receive illegal benefits or payments.

Health care fraud is not a victimless crime. It affects everyone—individuals and businesses alike—and causes tens of billions of dollars in losses each year. It can raise health insurance premiums, expose you to unnecessary medical procedures, and increase taxes.

The FBI is the primary agency for investigating health care fraud for both federal and private insurance programs.

The FBI investigates these crimes in partnership with:

• Federal, state, and local agencies
• Healthcare Fraud Prevention Partnership
• Insurance groups such as the National Health Care Anti-Fraud Association, the National Insurance Crime Bureau, and insurance investigative units

Common Types of Health Care Fraud

Fraud Committed by Medical Providers

• Double billing: Submitting multiple claims for the same service
• Phantom billing: Billing for a service visit or supplies the patient never received
• Unbundling: Submitting multiple bills for the same service
• Upcoding: Billing for a more expensive service than the patient actually received

Fraud Committed by Patients and Other Individuals

• Bogus marketing: Convincing people to provide their health insurance identification number and other personal information to bill for non-rendered services, steal their identity, or enroll them in a fake benefit plan
• Identity theft/identity swapping: Using another person’s health insurance or allowing another person to use your insurance
• Impersonating a health care professional: Providing or billing for health services or equipment without a license

Fraud Involving Prescriptions

• Forgery: Creating or using forged prescriptions
• Diversion: Diverting legal prescriptions for illegal uses, such as selling your prescription medication
• Doctor shopping:Visiting multiple providers to get prescriptions for controlled substances or getting prescriptions from medical offices that engage in unethical practices

Protect Yourself 

• Protect your health insurance information. Treat it like a credit card. Don't give it to others to use, and be mindful when using it at the doctor’s office or pharmacy.
• Beware of “free” services. If you're asked to provide your health insurance information for a “free” service, the service is probably not free and could be fraudulently charged to your insurance company.
• Check your explanation of benefits (EOB) regularly. Make sure the dates, locations, and services billed match what you actually received. If there’s a concern, contact your health insurance provider.

Prescription Medication Abuse

Creating or using forged prescriptions is a crime, and prescription fraud comes at an enormous cost to physicians, hospitals, insurers, and taxpayers. But the greatest cost is a human one—tens of thousands of lives are lost to addiction each year. Protect yourself and your loved ones by following this guidance:

• If you are taking opioids, take them exactly as prescribed by your doctor, ideally, for the shortest amount of time possible.
• Never share your medication with others.
• Explore non-opioid options with your doctor.
• Learn more about the risks of opioid use from theCDC.
• If you have unused or expired pain medications, take them to aDEA-approved take back site for disposal.

How to Report  

If you believe you have information related to health care fraud or someone you know may have been a victim of health care fraud,file a complaint at the FBI’s Internet Crime Complaint Center atic3.gov.

When reporting health care fraud—regardless of dollar amount—include as many of the following details as possible:

• Names of health care provider (i.e. doctor, facility, pharmacy, supplier)—include any information related to their license number or national provider number (NPI) if available.
• Relevant dates—date of service, date of claim, any dates of communication, payments, or receipt of services/items
• Description of services/items billed and dollar amount (you may attach a copy of your explanation of benefits or invoice if applicable)
• Were these services/itemsreceived?
• Did the fraud cause patientharm?  If so, explain.
• Method of communication, including phone numbers, email addresses, mailing addresses, and websites used by the perpetrator
• Insurance Carrier
• Location (city, state) of all parties involved to include beneficiary residence location and provider/facility/supplier location if known.
• If you are reporting items received in the mail, you may take aphotograph of the packaging label and items inside to include any marketing or instruction inserts.
• If you suffered a financial loss, please include themethod of payment, where you sent funds, including wire transfers and prepaid cards (provide financial institution names, account names, and account numbers)
• Descriptions of your interactions with the scammer and the instructions you were given
• Have you reported this to anyother agency? If so, who? Include agency name and any reference number provided. 

Whenever possible, you should keep original documentation, emails, faxes, and logs of communications. Copies or photographs of any items listed above can be attached to the complaint.

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