Where Medical Insurance Fraud Cases Run Rampant, and How to Spot It

August 24th, 2018 by Mike Bothwell

Prevent medical insurance fraud cases from robbing people in need of the care they deserve.

medical insurance fraud casesMedical insurance fraud cases don’t represent a victimless crime, and it doesn’t just affect big corporations. These types of crimes are directly responsible for shrinking benefits and higher costs. People who need insurance coverage get dropped every time insurers make adjustments. Anyone has the ability to make a difference by stopping insurance fraud in its tracks. Depending on the circumstances, doing so might add a few zeros to your bank balance.

Most Common Types of Healthcare Insurance Fraud

  • Billing for care never the professional didn’t provide
  • Misrepresenting details of care
  • Providing unnecessary care or prescribing unnecessary medication
  • Incorrectly diagnosing patients to substantiate expensive treatments
  • Failure to collect copayments
  • Offering kickbacks

The Most Common Problems

In over half of fraud cases, health care providers bill for services they never performed. The most worrisome cases involve multiple patients who many times suffer from some sort of disability. Their impairment makes them vulnerable to fraud or to threats by medical professionals who don’t want them to discuss what is (or rather, what isn’t) going on behind closed doors.

In many cases, patients don’t even see the provider. The visit is simply added to their bill. Offices then falsify patient records — or not. Investigators report that a majority of fraud cases get closed quickly because there is zero documentation to back up their false bills.

Both of these situations can be difficult to pinpoint unless you know a patient well. If you’re an in-home care provider, for instance, you can talk with the patient at length about what happened during their appointment and compare it against the bill. Likewise, if bills are arriving for dates and services the patient wasn’t involved in, there’s sufficient reason to ask more questions.

Misrepresenting Details of Care

When it comes to misrepresentation, many healthcare providers tell themselves they’re doing the right thing. They fudge dates or treatment types to ensure someone is paying for procedures their patients need. They might change locations or staff names around to ensure payments get spread around. People who benefit appreciate the results, so they rarely say anything to put a stop to it. However, most fraudsters don’t stop at simply helping their patients. They help money into their own pockets.

Take, for instance, the practice of changing dates. Clinics might perform two or three types of treatment during a single visit. The bill would include an office fee, exam fee, and specific treatment expenses. An office might choose to split this bill into three visits, each with their own office and exam charges.

Other Types of Fraud Can Hurt Patients

Other types of misrepresentation are dangerous for patients. For example, a fairly common type of fraud involves claims for therapy or treatment happening onsite when the patient performs it at home on their own. This can range from physical therapy to injections and wound care. Many of these practices aren’t covered by insurance because they’re not considered safe.

In other cases, doctors sign off on care that’s provided by staff without proper training. These kinds of clinics often bring in legitimate health providers to act as supervisors without letting them in on the details. Once they realize they’re dealing with an illegal operation, they might be too afraid of repercussions to come forward.

If bills come to your home detailing treatment performed on the wrong dates, in the wrong locations or in different ways than they’re delivered in reality, ask your health professional for an explanation. Medical billing is complicated and human error might have played a role, but there’s likelihood of fraud if it keeps happening.

Other types of fraud are becoming less common, but they are some of the most damaging in the industry.

How Fraud Robs Patients in Need of Critical Care

Throughout the 90s and early 2000s, one of the most common types of medical insurance fraud was writing bad prescriptions. Patients who didn’t need heavy-duty painkillers would get them, sell them and pay the doctor a little extra. Those scams are much less prevalent today because the government has gone out of its way to catch them. Unfortunately, it highlights exactly how fraud can cost patients in need.

The majority of community healthcare centers – facilities where low-income families go to receive the care they cannot afford anywhere else – do not prescribe pain medication. Urgent Care units won’t either. It takes an expensive trip to a family doctor or specialist to receive adequate pain management, and even then, a doctor might refer a patient to a specialty office. Few doctors will deal with the scrutiny of prescribing those kinds of drugs, even when they have a patient who would greatly benefit from taking them.

Access to quality, necessary care is at stake, and anyone can help secure it. If you’ve seen a business or health provider engaging in fraud, you have the ability to stop it.

Click to find out more about medical insurance fraud by contacting Bothwell Law Group online.

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