Health Insurance Fraud: A Growing Concern in the US

Health insurance fraud is a growing concern in the US, with billions of dollars lost each year. According to the National Health Care Anti-Fraud Association, the total estimated annual cost of health care fraud in the US is around $300 billion.

The majority of health insurance fraud cases involve individuals, not organizations. In fact, a study found that 70% of health care fraud cases involve individual perpetrators.

One common type of health insurance fraud is billing for services that were never provided. This can include submitting claims for procedures that were never performed or for services that were not rendered.

Health insurance fraud is a serious crime that can have devastating consequences for individuals, insurance companies, and the healthcare system as a whole. It occurs when someone intentionally submits false or misleading information to obtain health insurance payments.

Healthcare fraud is a crime committed by dishonest providers or consumers. They may bill for services not actually performed, falsify patient diagnoses, or misrepresent procedures to obtain payment for non-covered services.

Some common examples of healthcare fraud include upcoding, unbundling, accepting kickbacks, and waiving co-pays or deductibles and over-billing the insurance carrier.

Consumer health care fraud can also occur when individuals file claims for services or medications not received, forge or alter bills or receipts, or use someone else's coverage or insurance card.

Hard fraud involves a fake incident where the purpose is to collect an excessive amount of money from an insurance company. This type of fraud is often used to claim insurance coverage for a vehicle that has been damaged in a fake car accident.

Soft fraud, on the other hand, involves a valid reason to claim insurance but with some falsified information to gain more benefits. This can include exaggerating the damages of an incident or claiming serious injuries when only minor treatment is needed.

The cost of health insurance fraud is estimated to be around $68 billion annually, which is about 3 percent of the nation's healthcare spending. However, it's believed that the actual cost could be much higher, with some estimates ranging as high as 10 percent of annual healthcare expenditure.

Here are some examples of healthcare fraud:

Health insurance fraud is a serious issue that affects individuals, healthcare providers, and insurance companies alike. There are several types of health insurance fraud, including billing for services not rendered, upcoding of services, and duplicate claims.

One of the most common types of health insurance fraud is billing for services not rendered. This can include things like billing for doctor visits that never took place or for services that were never provided.

Upcoding of services is another type of health insurance fraud. This occurs when a healthcare provider bills for a more expensive service than the one that was actually provided.

Duplicate claims are also a type of health insurance fraud. This happens when a healthcare provider submits the same claim multiple times to try to get paid twice for the same service.

Here are some examples of health insurance fraud:

In some cases, healthcare providers may engage in soft fraud, which involves exaggerating the damages of an incident to maximize benefits and compensations. This type of fraud is not as serious as hard fraud, but it still involves a cost for the insurance company and its customers.

Billing issues are a major concern in health insurance fraud. Billing for services not rendered is a common scheme, where healthcare providers submit fake claims to Medicare for procedures that never actually happened.

This can involve forging signatures or using bribes to corrupt medical professionals. It's a serious offense that can result in significant financial losses for insurance programs.

Upcoding of services is another form of billing fraud, where providers submit false billing codes to obtain higher reimbursement. This can be done by billing for more expensive procedures than what was actually performed.

Healthcare providers may use upcoding to increase their profits, but it's ultimately the insurance programs that bear the financial burden.

Service Manipulation is a common tactic used by healthcare providers to commit health insurance fraud. Billing for services not rendered is one such example, where providers forge signatures or use bribes to obtain reimbursement for nonexistent services.

This can involve upcoding of services, where providers submit false billing codes to obtain higher reimbursement. For instance, billing for a more costly service than the one actually performed. Excessive services is another form, where providers bill for services that are not medically necessary.

Some examples of service manipulation include:

Service Manipulation involves altering the services provided to patients for personal gain. This can be done through various means, including upcoding of services, where healthcare providers bill Medicare for more costly services than those actually performed.

Upcoding of services is a common form of service manipulation, where providers submit false billing codes to obtain higher reimbursement. This can result in significant financial losses for Medicare and other healthcare programs.

Excessive services are another form of service manipulation, where providers bill for more services than required by the patient's condition. This can include medical equipment and services that are not necessary for the patient's care.

Here are some examples of service manipulation:

Unnecessary services are a form of service manipulation where providers bill for services that are not medically necessary. This can include procedures such as echo cardiograms for patients with non-cardiac conditions.

Kickbacks are also a form of service manipulation, where providers accept rewards for using specific medical services or products. This can include cash, gifts, or other forms of compensation.

Unbundling is a sneaky tactic used by some to manipulate service bills. By submitting bills in piecemeal, they make it seem like the services are staggered out over time. This allows them to charge more to Medicare, resulting in a higher payout to the party committing the fraud.

Bills for a particular service are submitted in a way that appears to be staggered out over time. These services would normally cost less when bundled together.

Medical discount plans can sound like a great idea, but some of them are scams. Scammers might claim you'll get "discounts of up to 70%", but savings with discount plans are often much less than promised.

Scammers might tell you that specific local doctors participate in the plan when they don't. Some dishonest plan promoters might even send you outdated lists. So, it's essential to do your own research and call your providers to confirm their participation.

Many states require medical discount programs to be licensed or registered. If someone is claiming that a medical discount program is health insurance, check it out with your state insurance commissioner's office. Medical discount plans are not insurance and they're not a substitute for health insurance.

Legitimate plans should be willing to send you written information and give you the chance to check out their claims before you enroll. If someone is pressuring you to sign up quickly or threatening you with missing out on a "special deal", it's a red flag.

Here are some signs of a medical discount plan scam:

Claims manipulation is a sneaky tactic used by some providers to get extra payments from Medicare. They might submit duplicate claims, where the same service is billed twice in an attempt to be paid twice.

This can happen when a provider changes small details, like the date, on a claim to make it look like a new submission. For example, instead of submitting exactly the same bill, they might change the date to try and get paid twice for the same service rendered.

Providers might think they can get away with this, but it's actually a form of health insurance fraud.

Reporting health care fraud is a serious matter that requires attention to detail and a proactive approach. If you suspect fraud, contact the FBI via their local office, telephone, or online tips form.

You can also report suspected fraud to your health insurance company's Special Investigations department, such as Cigna Healthcare's Special Investigations at [email protected] or by mail to Cigna Healthcare Special Investigations, 900 Cottage Grove Road W3SIU, Hartford, CT 06152.

To prevent health care fraud, be cautious when receiving services and ask questions about what you need and what it costs. Fill out, sign, and date one claim form at a time to avoid errors. Always protect your ID card and be careful about disclosing your insurance information.

Reporting health care fraud can be done through various channels. If you suspect fraud, contacting the FBI is a good place to start. You can reach out to them through their local office, phone, or online tips form.

If you want the government to actively investigate the alleged fraud, consider consulting with an experienced law firm that specializes in qui tam litigation under the False Claims Act. They can advise you on your rights, protections, and what evidence is needed to build a strong case.

There are different types of fraud, including business-related, family-related, financial-related, government-related, and other types. These categories help identify the scope of the issue.

Here are some specific ways to report health care fraud:

Protect yourself from health care scams by being cautious of unsolicited calls from people claiming to be from the government. Government agencies won't call you out of the blue to ask for money or personal information.

To verify the authenticity of a call, contact the government directly. For Medicare, call 1-800-MEDICARE (1-800-633-4227) or visit Medicare.gov. For the Health Insurance Marketplace, call 1-800-318-2596 or visit HealthCare.gov.

If you're considering a medical discount plan, research every claim it makes, including whether your doctor participates. Get the details in writing before signing up, and be wary of plans that charge a monthly fee for discounts on specific medical services.

To get a price quote for health insurance, visit HealthCare.gov and only enter your monthly income and age. Never provide personal financial information to get a quote.

Before signing up for health insurance, research any company offering coverage and check for complaints online. Look for reviews and see what others have to say.