The National Health Care Anti-Fraud Association estimates that over $50 billion is lost by health insurers and government agencies to health care fraud each year. This fraud is committed by patients, doctors, and even organized crime. While many view this as a victimless crime, the financial burden caused by health care fraud is one of the reasons that many in the United States have seen their benefits decrease while their premiums have gone up.
There are dozens of ways in which doctors, patients, and others can commit health care fraud, but below are some of the more common.
Fraudulent Billing To Get Services Covered — If you’re having a service done that you believe is not covered by your insurance company, and your provider assures you that he or she can get it covered; beware. The doctor may not be working with your insurance company to ensure coverage, but instead submitting a claim that misrepresents the services rendered. For instance, if you are seeking treatment for obesity and your plan does not cover weight loss services, the doctor may submit the claim without the diagnosis of obesity, and substitute instead a diagnosis for conditions commonly associated with obesity, such as high blood pressure or heart disease.
Filing Claims For Services Represented As Free — This scam involves doctors advertising “free” screenings for patients, often in low income areas or areas with high percentages of immigrants. These screenings are a method to gain access to a person’s insurance information so that the doctor can bill the insurance company for services that may or may not have been rendered. In the case of Dr. Felix Vasquez-Ruiz, the doctor was advertising free screenings in stores around Chicago. He gave his patients painful and unnecessary nerve tests and then billed their insurance companies for thousands of dollars in claims for them. As a rule of thumb, if a doctor advertises a “free” service, he cannot legally charge your insurance company for it.
Billing for Services that Were Never Rendered — This can take many forms. Sometimes a doctor will bill additional tests and services on top of services that were truly rendered, assuming the patient will not know the difference. Other doctors might be bold enough to submit claims for completely fictional dates of service. Doctors who do this typically go after immigrants and the elderly, who they know are less likely to question the practice.
Misrepresenting Eligibility to Gain Coverage — Most health insurance coverage has a series of eligibility requirements you must meet to obtain and/or remain covered under the policy. Occasionally people will misrepresent their relationships with the insured in order to gain coverage. For instance, a person might misrepresent his live-in girlfriend as his spouse in order to obtain coverage.
Altering a Bill To Receive Higher Payment — Most health insurance contracts stipulate that payment will go directly to the doctor. But with some plans, such as indemnity plans, the doctor is not under contract with the insurance company and the patient is entitled to have benefits sent directly to them. Because members often file their own claims under these types of plans, it is not uncommon to see claims that have had coding, services, or charges altered to attempt to receive higher payment from the insurance company. There have even been instances where claims for pets have been altered to attempt to receive reimbursement.
So what can you do? Pay attention to communications you receive from your insurance company. When you receive Explanations of Benefits, review them to see if the services detailed there are indeed what you received. If you suspect something is in error, call your insurance company and let them know. Health insurance companies have Special Investigations units that research health care fraud who will investigate your issue if necessary to determine if something illegal is going on. Investigations are typically confidential.