Finding high-quality health insurance coverage and paying for health insurance can be a complex process. From buying an adequate plan to finding a reputable in-network doctor and dealing with medical claims, policyholders are susceptible to criminals who find clever ways to profit off consumers who don't know the inner workings of the industry.
Healthcare fraud comes at a huge cost, both individually and to the country at large. The FBI notes that healthcare fraud in the United States alone costs tens of billions of dollars every year. This guide will show you the many insidious forms that health insurance fraud can take, how to spot and prevent a scam, and, finally, what to do if you or a loved one fall victim to health insurance fraud.
Types of Health Insurance Fraud
Fraud can occur at any step of the health insurance process, from buying coverage to receiving care. Here are some of the most common types.
1.) Medicare/Obamacare Fraud
Because Medicare is paid out through the government and not through a private insurance company, some scammers take advantage of the program's size and complexity by trying to slip fraudulent claims past Medicare administrators. In 2014 alone, it was estimated that Medicare improperly paid out $50 billion. The U.S. Government Accountability Office (GAO) explains that Medicare is a high-risk fraud program because it's difficult to navigate, making it easy for fake claims to slip through the cracks and go undetected.
Medicare fraud can happen at any point—when an insurance agent imposter tries to sell you a fake Medicare insurance plan, when a provider bills you incorrectly for health services that you may or may not have received or when a scammer calls you to verify personal information for your Medicare plan and uses that data to steal your identity. Open enrollment season is a common time for scammers to try to steal personal information from vulnerable Medicare users because if any changes are made to a plan, the user may not question someone calling to "verify" information.
2.) Ambulance Fraud
In an emergency, most people feel worried and flustered. Unfortunately, whenever people are going through a crisis, there will be other people trying to take advantage of them. In the heat of the moment, it can be hard to think about the cost of calling an ambulance or how it's billed and paid for, and fraudsters use that oversight to rack up unnecessary charges for ambulance services. An ambulance service provider might charge a patient for more distance than he or she actually traveled or add additional services that weren't used in the ambulance. These grifters are infamous for adding relatively small charges that they hope will be overlooked, but that translate into big profit for their own pockets over time. And as more ambulance service companies expand to provide ambulance transport for non-emergency situations, such as transporting patients in need of dialysis or even just to doctor's visits, the risk for fraud only increases.
3.) Community Mental Health Fraud
The mental health arena is particularly vulnerable to scams. Community health fraud generally involves billing patients and insurance companies for unnecessary or incomplete services. For example, the U.S. Department of Health and Human Services detailed one case that involved therapists billing insurance companies for one-hour therapy sessions for mental health patients, while the actual sessions only took 15 minutes. Some also billed for "recreational" services that actually meant just putting on a movie for patients to watch. Mental health fraud can also involve patients being prescribed unnecessary medications or providers getting kickbacks for using certain services. Mental health patients may be in such crisis that they don't realize they are being taken advantage of, which leaves them especially susceptible.
4.) Medical Identity Theft
Medical identity theft involves a criminal using personal information, such as your social security number or your health insurance policy numbers and codes, to either charge you fraudulently or collect benefits and payments under your name.
5.) Offers of Discount Plans and Cards
These discount plans and cards will ostensibly save you money on health care costs or supplies, but the National Association of Insurance Commissioners (NAIC) warns consumers to be careful when buying them. Some discount cards are legitimate, but according to the NAIC, they are not insurance and will not pay medical claims. Watch out for ads that bandy about words like "premiums" or "copayments" to fool you into thinking the discount cards are a low-cost insurance policy.
6.) Marketing Scams
In this lucrative scheme, fake insurance agents will collect high premiums from customers but not actually pay out any claims. In two years alone, the General Accounting Office found 144 fake insurance companies that were pulling this scam, resulting in more than $252 million in unpaid costs.
7.) Equipment and Supply Coverage Fraud
In this scheme, insurance companies will commit fraud by falsifying medical equipment claims, especially for the elderly or people with disabilities, who often require a lot of durable medical equipment. This scam might include anything from billing for equipment twice, deliberately shipping more equipment than your doctor orders, "forgetting" to issue returns, charging for a more expensive item than they actually give out or issuing false claims.
How to Protect Yourself
To avoid healthcare scams, you need to know how to identify reputable health insurance companies and agents, be aware of your rights as a consumer and understand how to protect your identity.
Determine Whether a Company or Agent is Reputable
Browse some plans on the Marketplace site,
so you can become familiar with the types of insurance companies that are available. When you narrow down your choices, look for signs that a company is reputable, such as websites that end in ".gov," which means they are associated with a governmental agency.
Check whether an insurance company is licensed in your state
Be suspicious of any unsolicited calls.
Insurance companies will never contact you directly to try to solicit any kind of personal information, including your credit card number or social security number.
Look for contact information.
A reputable insurance company will have an easy-to-find phone number to contact a company representative or agent. Try out the number—if the number doesn't work or it's extremely difficult to talk to a real, live person, it may be a sign the company should not be trusted.
If an offer sounds too good to be true, know that it probably is.
Know Your Rights
As a consumer, you have more rights than you may be aware of. If you purchase insurance through www.healthcare.gov, for example, you are entitled to a free, trained assistor who can provide state-specific advice on coverage. You also have the right to never give information out over the phone. Instead, request that the company or agent who is asking for the information send you an official letter in the mail.
You also have the right to know what's in your medical file, which will help you keep track of the healthcare services you're being charged for. The Federal Trade Commission explains that by federal law, you have the right to know what's in your medical files (although in some cases, you may have to pay to obtain copies of those files.) By law, you also have the right to order one free "accounting of disclosures" copy from each of your medical providers every twelve months. This accounting disclosure form lists everyone your provider sent your medical and insurance information to.
Protect Your Identity
To protect your identity, never give out your personal information, including your social security number and insurance number — especially if the alleged company or agent contacts you by phone or email asking for that information. Always use secure websites when filling out health forms online (check for an "https" rather than an "http" URL.) And make sure you have copies of privacy policies that disclose where your information will be shared. Also, before you throw anything away, you should shred any forms containing personal information, such as healthcare bills and statements, and remove labels from prescription bottles What to Do If You Become a Victim
How to Tell You've Been Defrauded
The Federal Trade Commission lists signs to look for if you suspect that you've become a victim of health insurance fraud, including:
Receiving the bill for a service or equipment that you never received
Getting called about medical debt you are unaware of
Noticing medical charges on a credit report that are not yours
Finding differences on your explanation of benefits from your insurance company to what services and office visits you actually had
Maxing out your insurance benefits suddenly
Being denied insurance coverage because of false medical conditions
How to Report Fraud
If you suspect you have been the victim of fraud or that an insurance company or provider is committing fraud, the FBI recommends first contacting your own health insurance company's fraud reporting number. Report Medicare fraud to 1-800-HHS-TIPS (1-800-447-8477) or online at Medicare.gov. Secondly, file a complaint with your state's fraud bureau by finding your state at the NCHAA website here. In addition, file a complaint with your state's Medical board.
Marketplace.gov explains that if someone steals your personal information, you can report the suspected identity theft online using the Federal Trade Commission's online Complaint Assistant. In addition, call your local police department. You can also contact the Health Insurance Marketplace call center at 1-800-318-2596 (TTY: 1-855-889-4325) for assistance.
When to Pursue Legal Action
The Coalition Against Insurance Fraud states that, in some cases, civil suits can send a strong message and help stop insurance fraud. Consult with an attorney and a representative from your insurance company if you are considering legal action.
Leigh McKenna is the director of government & public affairs with the National Health Care Anti-Fraud Association (NHCAA). Here she provides her expertise on the kinds of healthcare fraud to watch out for and how to protect yourself and your loved ones.
Expert Advice on Common Health Insurance Scams & How To Avoid Them
- What kind of fraud do you see the most often?
- Who is behind all this healthcare fraud?
- How much does healthcare fraud really cost the nation?
- What's the best way protect myself and my loved ones against health insurance fraud?
- What are some new scams to watch for?
- What do scammers look for in a victim?
- What should you do if you are the victim?
Director of Government & Public Affairs
Your Healthcare Insurance Company
Make a copy of all of your insurance cards, including policy and contact numbers, and reach out to your insurance company if you believe you've been scammed.
The Senior Medicare Patrol
The SMP is dedicated to helping protect seniors from healthcare fraud.
A one-stop-shop for state reporting, this website lists how to report health care fraud by state.
You can call this fraud tips hotline if you see signs of healthcare fraud.
Coalition Against Insurance Fraud
This non-profit agency is dedicated to advocacy, information, and outreach on insurance fraud.
About Chaunie Brusie