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Health Care Fraud

What is Healthcare Fraud?

Healthcare Fraud is the intentional deception or misrepresentation of healthcare transactions by a provider, employer group, employee or member for the sake of receiving an unauthorized benefit or financial gain. Individuals convicted of this type of crime face imprisonment and substantial fines.

Most Common Types of Fraud:

Provider Fraud

  • Billing for services, procedures and/or supplies that were not provided
  • Billing that appears to be deliberate application for duplicate payments of services
  • Billing for non-covered services as covered items
  • Performing medically unnecessary services in order to obtain insurance reimbursement
  • Incorrect reporting of diagnosis or procedures to maximize insurance reimbursement
  • Misrepresentation of dates, description of services, or subscribers/providers
  • Providing false employer group and/or group membership information.
Member Fraud
  • Using someone else's coverage or insurance card
  • Filing claims for services or medications not received
  • Forging or altering bills or receipts
Employer Fraud
  • False portrayal of an employer group to secure healthcare coverage
  • Enrolling individuals who are not eligible for coverage
  • Changing dates of hire or termination to expand dates of coverage

How to report Healthcare Fraud?

  • You can E-Mail NetCare directly and report a possible fraud case
  • You can call NetCare at (671) 472-3610 extension 225
  • You can write to NetCare at 424 West O'Brien Drive, Suite 200, Hagatna, Guam 96910

How Can Members Avoid and Prevent Healthcare Fraud?

  • Ask your healthcare provider questions about your treatment plan, diagnosis and services received
  • Question advertisements or promotions that offer free tests, treatments or services
  • Safeguard your NetCare member ID Card, and be careful about disclosing your insurance information.
  • Be sure your Explanation of Benefits (EOB) and medical bills are consistent with services rendered

What Does NetCare do to fight Fraud?

NetCare's Audit and Recovery Department (ARD) examines possible incidents of fraud. The ARD receives complaints or leads from a number of resources including members, providers, employers and other healthcare companies. After receiving a report of fraud, the ARD investigates the allegation and works with the appropriate agencies/groups to resolve the issue.