Fraud in Health Care

Health care fraud has become such a major issue in our society that it is considered a high priority area within the FBI’s Complex Financial Crime Program – each office has personnel specifically assigned to investigate health care fraud matters. That fact alone shows how prominent this issue has become. To put some dollars to this problem, the Federal government won/negotiated over $2.3 billion in health care fraud judgments and settlements in 2014 alone. The National Health Care Anti-Fraud Association estimates, conservatively, that health care fraud costs the nation about $68 billion annually. While there are no solid statistics on how much is lost or embezzled in the health care system, but in 2012 Donald Berwick and  Andrew Hackbarth estimated that fraud added as much as $98 billion annual Medicare and Medicaid spending.

There are a number of different types of health care frauds, the following are just a few examples and explanations:

  • Upcoding – going in for an annual physical and the health care provided bills for an emergency visit.
  • Unbundling – getting billed for a number of services individually when they could be combined into one service. This provides more in reimbursements to the provider since individually, the costs of services are more expensive than bundled together.
  • Billing for Unnecessary Services – going in for an appointment and getting unnecessary blood work, x-rays or services performed.
  • Billing for Services or Items Not Furnished – not receiving any services, but the health care provider billing insurance companies for these services.
  • Medical Identity Theft – misuse of a person’s medical identity to wrongfully obtain health care, goods, services or funds.

Why is this important information to be aware of, many of the fraud scheme don’t effect the bottom line cost to the individual? It is important because each scheme involves the theft or misuse of a patients’ medical information.

To protect and prevent your information and yourself, it is important to safeguard your insurance cards and benefit information and ensure when you receive medical supplies that they are actually the items you ordered.

The best way to determine if your information is being utilized without your knowledge is to take a good look and review all of the explanations of benefits and information sent from your insurance company.