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How Insurance Agents Identify Fraudulent Insurance Claims

fraudulent insurance claims

fraudulent insurance claimsEach year, somewhere between three to ten percent of money spent by the government on healthcare is spent on fraudulent insurance claims. Fraudulent insurance claims are becoming increasingly common. However, that doesn’t mean they have become easy to spot. In fact, the individuals committing Medicare insurance fraud have learned how to hide their fraudulent activity well.

What Are Some Signs of Medicare Fraud?

The United States government relies heavily on individuals who are willing to blow the whistle on providers who are committing fraud and stealing money from Medicare. Because of this, insurance agents are learning to be hyper-vigilant. They watch closely for suspicious activity in each and every claim they manage. Insurance agents are learning to identify fraudulent insurance claims by watching for the most common types of Medicare insurance fraud, which include:

Duplicate Billing

In many cases, healthcare professionals will try to bill for a service more than once as a way to make more money.

Separate Billing of Services Normally Billed as One

There are specific procedures, such as diagnosed blood tests, which are typically billed as one. For instance, a complete blood count contains multiple tests but is almost always billed as one procedure. Healthcare providers may bill the CBC tests as one, and then bill for each test in order to receive double payment.

Billing for Services Never Received

In some cases, healthcare professionals will bill Medicare for services a patient never received. Medicare insurance agents can watch for billings that seem out of place or do not match up with a patient’s health history.

Medicare ID Sharing

More frequently, Medicare ID numbers are being shared among multiple people. Healthcare providers may also use them to bill for services for patients they haven’t seen. Insurance agents watch carefully to make the ID number being uses matches with the name on the claim.

In addition to watching for the most common types of Medicare insurance frauds, insurance agents carefully consider the calls they get from Medicare clients. People may call with concerns or confusion concerning a claim description they received in the mail. This red flag signifies the possibility of fraud. The client is the most reliable source for understanding which billings are accurate. So, insurance agents should never dismiss their concerns about inaccurate billing.

What Should You Do If You Suspect Fraudulent Insurance Claims?

If you are an insurance agent or patient who has concerns about a health provider, speaking with a fraud attorney who has extensive experience working with fraudulent insurance claims is a good place to start. A team member at Bothwell Law Group can look carefully at your suspicions. Then we can help you determine whether you have grounds for a lawsuit.

Contact our skilled fraudulent insurance claims attorneys at Bothwell Law Group by calling 770.643.1606 today.

Top Medical Insurance Fraud in the News

Medical Insurance Fraud

Medical Insurance FraudOf all cases of medical insurance fraud that occur each year, Medicare fraud is the largest source. In 2014, fraudsters scammed Medicare for over $60 billion, and over 2,000 providers have been caught defrauding Medicare. Pursuing Medicare fraud can be difficult due to the prevalence of fraud as well as the sheer number of people involved in defrauding Medicare.

What Is Medical Insurance Fraud?

Medical insurance fraud occurs when a provider or consumer intentionally submits fraudulent information that is used to determine health care benefits payable. Because of the cost of health care and medical equipment, the idea of pocketing the payout of billing for services or equipment that were not rendered is a tempting one for providers and consumers alike. While Medicare is the organization that is most affected by fraud, it can affect any heath insurance company, and can be perpetuated by individual doctors as well as organized groups.

Medicare and related government-provided coverage is the most common target for insurance fraud for a few primary reasons:

  • Over 54 million people are covered by Medicare, and the organization pays out over $600 billion each year.
  • The organization is subjected to the loosest monitoring by those in charge.
  • Billions of dollars are left largely unguarded and ripe for targeting by scam artists.

How Is Medical Insurance Fraud Perpetuated?

There are various ways providers and consumers can commit medical insurance fraud. Some of the most common seen by investigators include the following:

  • Billing for medical equipment, medication, or services that were not actually rendered, received, or performed.
  • Falsifying a patient’s diagnosis to justify procedures, equipment, surgery, or other procedures that were not medically necessary.
  • Upcoding and Unbundling. Upcoding is billing for a service more costly than the one performed. Unbundling is the billing of each step of a procedure as separate procedures.
  • Accepting kickbacks in exchange for patient referrals.
  • Waiving co-pays or deductibles and over-billing the insurance company.
  • Forging or alteration of medical bills or receipts.
  • Using someone else’s health coverage or insurance card.

Combating Medical Insurance Fraud – a Lengthy Process

Medical insurance fraud is a crime that has serious ramifications for everyone. Every time fraud is committed, it raises the cost of health care for millions of other Americans. So it is important that medical insurance fraud is pursued and prosecuted in order to recoup the amounts that were defrauded.

The challenge in pursuing insurance fraud is finding individuals who are both willing to cooperate with investigators and who have sufficient evidence to back up their claims. Even when a whistleblower contacts authorities with information, it can be a long and arduous process to gather more evidence and bring a court case. But these cases must be pursued in order to help combat the rapidly-rising costs of health care in the United States.

If you have witnessed or participated in medical insurance fraud, you will need protections should you choose to come forward as a whistleblower. Contact the skilled whistleblower attorneys at Bothwell Law Group by calling 770.643.1606 today.

Endangering Babies For Profit

Bottom line: Medicaid pays the same amount for a Midwife as for an Ob-Gyn. Thus, some hospitals have a financial incentive to push even the high-risk patients to use Midwives rather than doctors. Unfortunately, this is happening at considerable risk and sometimes serious damage to patients.

$100 Million Lawsuit Filed

$100 Million federal law suit was filed against Indiana University Health and 2 associated medical organizations, Healthnet and MDWise.  Allegations state “Contrary to their carefully crafted image of offering compassionate care for the indigent, two of the largest healthcare providers in Indianapolis put poor, pregnant women and their newborn babies at risk with a fraud scheme designed to increase revenues, regardless of the law or the risks to the most medically-fragile patients.”

A doctor at the hospital filed a complaint after what she saw there. Dr. Judy Robinson is the former medical director at the hospital. “I’m filing this lawsuit because of the abysmal care I witnessed these people receiving. And, after approaching IU Health, nobody would do anything.” Robinson pointed out that patients who should have received monitoring during their pregnancy didn’t receive the monitoring. “There was little to no physician involvement in the obstetrical care of these high-risk patients.”

Under the state Medicaid reimbursement rules, “Nurse midwives may not provide services to members with medically high-risk pregnancies. However, according to the lawsuit, lower-cost nurse midwives handled high-risk patients, in violation of the Medicaid regulations.

To make it worse, the hospital filed false-claims with the state and federal government for doctor services the patients never received. The hospitals are using midwives but getting reimbursed for using doctors.

Babies Permanently Damaged

According to Dr. Robinson, at least 3 babies suffered permanent neurological damage and 17 infants nearly missed a tragic outcome.

Watch the TV interview here. 

Thanks to whistleblowers like Dr. Judy Robinson, the lives of children may be dramatically changed for the better.

If you think you may have a whistleblower case, have a confidential talk with a whistleblower attorney as soon as possible. These are time-sensitive matters. A whistleblower attorney knows how to protect your rights and get results.