ATRIO Health Plans is committed to detecting, preventing, and correcting healthcare fraud, waste, and abuse because it affects everyone. ATRIO wants to make sure you know what it is, how to spot it, and how to help us prevent it.
The United States spends a substantial amount of money on health care fraud. Resources estimate that the financial losses due to health care fraud are in the tens of billions of dollars each year. A conservative estimate is 3% of total health care expenditures, while some government and law enforcement agencies place the loss as high as 10% of our annual health outlay, which could mean more than $300 billion.
In 2022 the U.S. Justice Department recovered more than $2.2 billion dollars from lawsuits involving healthcare fraud and false claims.
The department’s $2.2 billion recovery in fiscal year 2022 was the lowest since 2008 and marked a sharp decline from 2021 when recoveries exceeded $5.6 billion, the second largest in a single year since tracking began in 1986. 2021 marked the 14th straight year of increasing recoveries.
Due to the pandemic, the recoveries in fiscal year 2022 also reflected the department’s focus on new enforcement priorities, including fraud in pandemic relief programs and alleged violations of cybersecurity requirements in government contracts and grants.
There are several ways health care practitioners, pharmacies, and members can commit fraud. A few examples include:
To learn more, go to:
When it comes to your health insurance, if something doesn’t feel right, report it to us. Do not be concerned about whether it is health insurance fraud, waste, or abuse. Report your concerns to the ATRIO Customer Service Department. The ATRIO Compliance Department will investigate and make the proper determination.
Health care fraud: Includes health insurance fraud, drug fraud, and medical fraud. Health insurance fraud occurs when a company or an individual defrauds ATRIO, an insurer or government health care program, such as Medicare (United States) or equivalent State programs. The manner in which this is done varies, and persons engaging in fraud are always seeking new ways to circumvent the law.
In other words:
Fraud: Knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program; or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program.
Waste: Overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.
Abuse: Includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and or/intentionally misrepresented facts to obtain payment.
The purpose of phishing emails is to steal your identity or personal information. These emails may imitate the logos, style and language used by reputable companies. Protect yourself from these scams by learning to identify them.
Look for the following:
If you receive a suspicious email related to your health insurance, services or supplies that you would like to report, please call 1-877-672-8620 (TTY 711).
If you receive a phone call from someone offering free genetic testing, free orthotic braces, free foot spas, or anything else, don’t be a victim.
Try to capture the phone number the call is coming from, using either caller ID or the recent call history on your cell phone.
Do not give ANY personal information or answer any of their questions.
Try to obtain:
Any other information may be useful for an investigation by ATRIO. Report the call to the ATRIO Customer Service department at 1-877-672-8620 (TTY 711).
You May Also Report Unwanted Calls to the Federal Communications Commission (FCC).
Phone: 1-888-225-5322TTY: 1-888-835-5322
Para presentar una queja en español, llamar al: 888-CALL-FCC (888-225-5322).
Please report suspected health insurance fraud, waste, or abuse to ATRIO’s Medicare Compliance Team by clicking the link below.
A new Combating Medicare Parts C and D Fraud, Waste, and Abuse (FWA) Web-Based Training course is available through the Medicare Learning Network®. Learn about:
You may report suspected fraud, waste, or abuse directly to the OIG Hotline at: 1-800-447-8477 TTY / 1-800-377-4950 or go to https://oig.hhs.gov/about-oig/about-us/index.asp
View recent fraud alerts or schemes published by the OIG: Consumer Alerts Webpage