Insurance fraud by policy holders and others

Insurance fraud by policy holders and others is on the upswing, and people aren’t very outraged about it. Some people think they’re just getting even with a large company, rather than committing a crime, when they defraud an insurance company. But everyone ends up paying for losses due to fraud through increased insurance premiums, higher taxes for government-sponsored programs such as Medicare, more expensive doctor visits, and more expensive prescription drugs.

Both patients and providers can commit fraud. Insurance frauds include

- Adding to claims expenses for services not delivered or inflating the cost of services.

- Lying on applications or withholding material information.

- Submitting false claims.

- Faking injuries and illnesses.

- Medical quackery (pretending to practice medicine).

- Obtaining the same prescription drugs from several doctors.

- False coverage schemes, such as when an “insurance company” accepts your premiums but doesn’t pay your claims.

- Substituting a covered diagnosis for a routine checkup.

Insurance companies are fighting back to a greater and greater extent. Insurers are diligently pursuing perpetrators of fraud in every way possible, including using special investigative units and high-tech data tracking. The Department of Health and Human Services (HHS) asks that Medicare recipients review their Medicare statements. If Medicare recipients find a suspicious charge, they should call their doctor or the HHS fraud watchdog line at 800-447-8477.

Don’t be a victim of fraud. Keep your eyes open and watch for the following:

- Free testing or screening offers that involve showing your health insurance ID card or Medicare card

- Doctors or other providers who want you to sign a claim form before providing a service

- Doctors or other providers who explain that they can prepare a bill so a charge that an insurance company doesn’t usually cover will be covered

- Medical laboratories or health clinics that bill for tests or other services that they didn’t provide

- Doctors who bill for inpatient hospital services on dates you weren’t in the hospital Keep fraud at a minimum with these measures:

- Ask your doctor and other providers whether the treatments and services they prescribe are medically necessary and what options are available.

- Always check carefully the Explanation of Benefits (EOB) that you receive from your insurance company or from Medicare.

Look for charges for services that you didn’t receive, treatments that were more complex than the ones you received, and multiple charges for a service that you received only once.

- When you buy health insurance coverage from an agent or company you’re not familiar with, contact your state’s department of insurance to verify that the company is licensed to operate in your state. Don’t buy insurance from an agent who offers you a kickback. Report these types of fraud to your state insurance department.

- Read the fine print in mail promotions. Report deceptive mail promotions to your local postmaster.

- Don’t trust a company that wants you to pay your premiums in cash or pay a full year’s worth of premiums at one time.

- Don’t give in to “last chance” opportunities to buy a policy.

- Never sign a blank insurance form.

- Have someone you trust perhaps a knowledgeable friend, accountant, or attorney review any policy you’re unsure of.

Seniors may be especially vulnerable to fraud. When seniors buy Medigap policies, they sometimes fall prey to crooked salespeople who try to sell policies with too little or improper coverage or to people who don’t need coverage.