In healthcare, fraud refers to knowingly and willfully obtaining, or attempting to obtain, money or property through false representations or promises. Waste is performing unnecessary services, overutilizing services, or billing for unnecessary services all of which result in avoidable costs to the system. Abuse results from activities that are not done in accordance with generally accepted industry standards, leading to more unnecessary payments and services. These harmful activities can be performed by medical providers, businesses, or a health plan’s members.
FWA is estimated to add up to as much as 35% of all healthcare spending in the United States.1 It’s a significant problem in the industry that medical providers, hospitals, insurers, and other parties face daily. This can lead to poorer medical outcomes for you and higher costs for everyone.
Evry Health’s Special Investigations Unit (SIU) works to detect, stop, prevent, investigate, and fix all forms of fraud, waste, and abuse. One way this group can do its job is through helpful reports of suspected FWA from our members, physicians, and the public at large.