Health insurance fraud is a serious problem that costs insurers millions of dollars every year and affects the way patients feel about doctors and other health care providers. Many of the more common types of frauds allow doctors to charge patients more and put money back in their own pockets.
Fraudulent Billing
One of the more common types of health insurance fraud is something called fraudulent billing. Fraudulent billing occurs when a doctor or medical facility bills a patient for a treatment that the individual did not receive, but it can also refer to other errors that appear on a patient’s itemized bill. The facility mails a copy to the patient’s insurer, the insurer pays the total amount and the facility receives money for procedures not actually done. Even if the insurer negotiates the price down, the facility will still receive money from that fraudulent bill.
Medical Identify Theft
Many think of identity theft in terms of personal finances. They imagine someone taking another person’s social security number and other personal information to apply for credit cards and secure loans. Medical identify theft is a type of health insurance fraud that occurs when an individual steals the medical information of another to obtain health care. This can include someone who steals a Medicaid or Medicare card from a loved one or someone who uses a friend’s insurance card or personal information to get treatment at a local hospital. The victim of identity theft may be responsible for paying that person’s medical bills.
Erroneous Treating
When a patient meets with a doctor, the doctor is responsible for deciding what is wrong with the patient and how to treat that person. Health insurance fraud can include something called erroneous treating, which is when the doctor treats a patient for conditions that he or she does not have. The doctor may even refer the patient to another doctor for a specialized treatment in exchange for that second doctor giving the first doctor money for that referral. Erroneous treating can also include doctors sending bills to insurance companies for treatments and procedures not actually performed.
Required Procedures
Another type of fraud occurs when a doctor charges a patient or insurer for services or procedures that are not medically necessary. This often relates to cosmetic procedures. If a patient wants to change his or her nose but insurance will not cover the cost of the surgery, the doctor might claim that the patient has a deviated septum and that a nose procedure is medically necessary for the health of the patient. Many insurance companies now require that patients seek a second opinion and look closely at cosmetic procedures before paying out.
Overcharging Patients
The National Health Care Anti-Fraud Association considers considers overcharging patients as a type of health insurance fraud. When medical professionals complete procedures, they provide patients and their insurers with a bill for those services. Most doctors will bundle those services to bring down the total cost. Doctors who overcharge will separate the procedure into multiple steps and charge a separate amount for each step. If a patient needs an abscess lanced, the doctor might charge for the initial exam, administering a numbing agent, lancing the boil, dressing the wound and for aftercare instructions sent home with the patient.
Health insurance provides those insured with financial help for medical services. Any frauds perpetrated by doctors or patients will cause insurance costs to rise. Some examples of health insurance fraud include doctors who overcharge their patients, fraudulent bills sent to patients and insurers and claiming that procedures are medically necessary to force insurers to cover those procedures.
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