Answers to Frequently Asked Questions (FAQs)

Q:  What is health care fraud? 

A:  The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), defines health care fraud broadly as “. . . knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefits program to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money owned by, or under the custody or control of, any health care benefit program.”  (42 U.S.C. Section 1320a -7a1).

More simply put, health care fraud is an intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, or the entity or to some other party” (National Health Care Anti-Fraud Association).

Q:  Why should I care about health care fraud?

A:  Health care fraud is not a victimless crime.  It has an enormous adverse impact on the quality of health care while also imposing higher costs on consumers, employers and taxpayers.  The financial losses to health care fraud nationwide are estimated to range from $75 billion to $250 billion a year (National Health Care Anti-Fraud Association).  Health care fraud can also harm people who are subjected to unneeded or inappropriate health care services – or services by providers who are not licensed or qualified to provide them.

Q:  What should I do if I suspect health care fraud?

A:  If you suspect health care fraud:

  • Call your health insurance company immediately.
  • You can also contact the agency in your state responsible for fighting health care fraud.
  • You can file a complaint with the appropriate Medical Board in your state.

If you suspect fraud in the Medicare program, report it:

By phone at 1-800-HHS-TIPS (1-800-447-8477)

By FAX to 1-800-223-2164 (no more than 10 pages please)

By e-mail to [email protected] 

By mailing:

Office of the Inspector General
HHS TIPS Hotline
P.O. Box 23489
Washington, DC 20026

Q:  I’ve heard of identity theft.  But what is medical identity theft?

A:  Medical identity theft involves:

  • Using stolen identity information to get medical goods or services, or
  • Using stolen identity information to falsify medical records and make fraudulent claims for payment for medical services or procedures.

Medical identity theft can leave its victims’ medical records filled with incorrect information.  This can haunt a medical identity theft victim for years and lead to inappropriate – perhaps even dangerous – mistakes in the health care treatment the victim receives.  A medical identity theft victim can also find that his or her medical benefits have been used up by the medical identity thief.