Health Insurance Fraud is a crime. It occurs when a healthcare provider or consumer intentionally provides false or misleading information to a healthcare insurance company in an effort to obtain unauthorized payment or benefits. Although the exact amount of theft through insurance fraud is hard to measure, it is estimated tens of billions of dollars annually are misappropriated through scams and schemes by healthcare providers and consumers. This not only impacts the insurance companies, it impacts everyone. The more revenue lost due to fraud, the higher insurance premiums rise to compensate for that loss. You can help prevent Health Insurance Fraud simply by educating yourself, making sure it doesn’t happen to you and reporting it when you suspect it has.
Examples of provider fraud
- Billing for services not actually performed.
- Duplicate claims: submitting a second, slightly different claim, in an attempt to be paid twice for the same service.
- Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary.
- Misrepresenting procedures performed to obtain payment for non-covered services, such as cosmetic surgery or massage therapy.
- Upcoding: billing for a more costly service than the one actually performed.
- Unbundling: billing each stage of a procedure as if it were a separate procedure.
- Accepting kickbacks for patient referrals or for providing a service, test or product.
- Waiving patient co-pays or deductibles and over-billing the insurance carrier or benefit plan.
- Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.
- Capping: the illegal referral of clients to legal and medical offices for a fee.
- Balance billing: the practice of billing a patient for the difference between what the patient’s insurance covers and what the provider charges for a service.
- Prescription Fraud.
- Durable Medical Equipment Fraud.
Examples of consumer or patient fraud
- Providing false information on an insurance application.
- Filing claims for services or medications not received.
- Forging or altering bills or receipts.
- Using anther persons identifying information to obtain or pay for healthcare insurance benefits.
- Lending insurance cards.
- False dependents.
- Forged or fictitious prescriptions.
- Utilizing more than one doctor to receive the same or other controlled or addictive medication for which there is no medical need.
The following is an interesting article in by Charles Piper in Fraud Magazine. Piper describes, from an investigator’s point of view, how and why some providers cheat the healthcare insurance system.