Learn how to recognize, report, and protect yourself from health care fraud and abuse.
Health care fraud and abuse refers to deceptive practices in the health industry that lead to undeserved profit. These schemes cost the nation billions of dollars each year and result in higher health insurance premiums and out-of-pocket expenses for consumers.
Health care fraud is a deliberate deception or misrepresentation of services that results in an unauthorized reimbursement.
Health care abuse refers to practices that are inconsistent with accepted medical, business, or fiscal practices.
These practices can take many forms, the most common including:
- Health Insurance and Medical Billing
- Medicare and Medicaid Fraud
- Home Health Care Fraud
- Drug Fraud and Abuse
The Consumer Protection Division of the Office of the Attorney General aims to help educate consumers on how to recognize fraud and abuse and how to file a complaint with the appropriate agency.
Types of Health Care Fraud
Health Insurance and Medical Billing
Health insurance and medical billing fraud occurs when a health care provider or individual deceives an insurer in order to receive greater reimbursement.
Examples of health insurance and medical billing fraud are:
- Billing for services not actually performed
- “Upcoding,” or billing for a more expensive service than the one actually performed
- “Unbundling,” or billing each stage of a procedure as if it were a separate procedure
- Falsifying a patient's diagnosis to justify procedures that aren't medically necessary
- Accepting kickbacks for patient referrals
- Waiving patient co-pays or deductibles and over-billing the insurance carrier
Medicare and Medicaid fraud is medical billing fraud specific to these government benefit programs. It is when a health care provider claims Medicare or Medicaid health care reimbursements that they are not entitled to in order to dishonestly collect money.
File a Medicaid Fraud Complaint
The Attorney General’s Medicaid Fraud Control Unit investigates allegations of Medicaid fraud. To file a Medicaid complaint, contact the Austin headquarters.
- Mail: Medicaid Fraud Control Unit at the Office of the Attorney General, P.O. Box 12307, Austin, TX 78711-2307
- Email: [email protected]
- Phone: (512) 463-2011
- Fax: (512) 320-0974
Home Health Care Fraud
Home health care fraud is when home health agencies bill insurers, government benefit programs, or homebound patients for unnecessary services or for services that were never delivered.
This can also fall under Medicare or Medicaid fraud if the homebound patient receives home care as part of either benefit program. It is fraud if claims are submitted that are not compliant with government program requirements.
Drug Fraud and Abuse
There are a few common types of drug fraud and abuse: drug pricing fraud, counterfeit drug fraud, and drug diversion abuse.
- Drug pricing fraud is when a physician dishonestly prescribes unnecessary medication to a patient in order to profit from the sale.
- Counterfeit drug fraud is when a physician knowingly pushes stolen, expired or altered or fake prescription drugs.
- Drug diversion abuse is when a health care worker does not administer a patient’s medication but keeps it for personal profit.
Report Fraud, Waste, or Abuse to HHSC
You can report fraud, waste or abuse by recipients or providers in the Texas Health and Human Services by visiting the HHSC website.