Humana Works to Prevent Health Care Fraud

In one case, a patient visits provider after provider, complaining of the same symptoms to obtain multiple prescriptions for a medication. In another, Humana receives a raft of claims from a lab – only to discover a con artist has bought a lab, rebilled all existing records and vanished.

In either case, the verdict is the same. Someone is committing health care fraud, risking the well-being of patients and causing needless expense and headaches for patients, providers and insurers.

The National Health Care Anti-Fraud Association (NHCAA) reports that in 2003 at least 3 percent of the nation's $1.7 trillion health care outlay was fraudulent. That amounts to $51 billion lost to fraud.

For 20 years, Humana has worked to stop health care fraud and abuse, according to Jean Sexton, area director. The company's efforts are required by many government bodies. Forty states have insurance fraud bureaus, 20 states require Humana to have an anti-fraud plan in place and 42 states require Humana to report suspected fraud.

"We're trying to take a more proactive approach," Sexton explained. "Rather than waiting for fraud to be referred to us, we are doing data mining and other work to identify problems at an early stage."

How fraud happens
Fraud and abuse of health plan policies can happen in many ways. Often, physician practices are on the front lines, Sexton said.

"If a practice suspects something is wrong, we hope its staff will let us know," she said. "Practices can help keep their own costs down by working with us to avoid paying out fraudulent claims – not to mention the medical risks if a patient is doing something like taking more drugs than he or she ought to be."

In addition, fraud can happen when:

• People use someone else's health insurance identification card. Some people actually sell insurance cards. Look for members "juggling" benefits by using different ID cards.
• Members submit claims themselves and alter the bills to obtain additional reimbursement.
• Criminals steal health care information to commit identity theft.
• Ancillary providers bill equipment for patients who are deceased.

Pharmacy fraud
Examples of pharmacy fraud are as follows:

• Filling less than the prescribed quantity of a drug
• Billing for brand name when generic drugs are dispensed
• Billing multiple payers for the same prescriptions
• Dispensing expired or adulterated prescription drugs
• Forging or altering prescriptions
• Prescription refill errors
• Examples of pharmaceutical manufacturer fraud are as follows:
• Lack of integrity of data to establish payment and /or determine reimbursement
• Kickbacks, inducements and other illegal remuneration
• Inappropriate relationships with physicians
• Illegal usage of free samples

Humana's Special Investigations Unit (SIU) reports suspected fraudulent activity involving the Part D Prescription Drug program to the appropriate Medicare Drug Integrity Contractor (MEDIC).

What Humana does
Humana is a member of the NHCAA. Special Investigations Unit team members also share information with other carriers and stay up to date on current fraudulent schemes through the Midwest Insurance Association. Occasionally, an organization, such as the FBI, approaches Humana to research an issue. Humana also receives tips from members, health care providers and community members.

Occasionally, Humana's data mining turns up a question mark.

"In those cases, we might work with a practice or a provider to facilitate proper coding," Sexton said.

For more information or to report suspected fraudulent activity contact the following:

Humana
Special Investigations Unit
1100 Employers Blvd.
Green Bay, WI 54344
Phone Number: (800) 558-4444, ext. 8187
Fax Number: (920) 617-1594
Email: siureferrals@humana.com

Or you may call Humana's toll-free Ethics Help Line at (877) 584-3539.
You may remain anonymous. Help line staff members are not Humana employees.

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