Avoid Becoming a Victim of Healthcare Fraud

colleagues doctors discusses findings from the patient's cardSo what if your provider files false claims on you?  Your insurance company will make it right…..right? In healthcare, the written record is the law.  So without oversight and review of that record by the patient before claims are submitted, the burden of proof for fraudulent claims is extremely challenging.

Why does this matter to you?

  • Every false patient diagnosis remains a part of your documented medical history, at least in the health insurer’s record. You can ask for an appeal or request to send in a note of clarification, but few people know how.
  • Victims of medical identify theft could receive the wrong medical treatment or even become uninsurable for life and health insurance coverage depending on what fraudulent notes are included in their record. What is worse, is these victims may never know of these errors or even never know until it is too late.
  • You could be subjected to dangerous medical procedures, just for greed.

Tips to avoid being a victim of healthcare fraud:

  • Protect your health insurance ID card like you would a credit card.
  • Report fraud immediately to your insurance company.
  • Be an informed consumer of healthcare. Know what services you have received, keep good records of your medical care and closely review all medical bills you receive.
  • Read your health insurance policy and EOB statements.

Yet another example our broken healthcare system: It does not allow the patient to hold the physician accountable for services rendered or review medical notes submitted before insurance issues payment. In my opinion, this must be changed in order to better protect healthcare consumers.

For more information visit:
https://www.nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-fraud.aspx

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/fwa-factsheet.pdf

3 thoughts on “Avoid Becoming a Victim of Healthcare Fraud”

  1. A number of years ago I underwent in an outpatient setting three biopsies of 3-6 mm each. The biopsies were sent to a pathologist for study with a microscope. By the end of the week I learned there was no cancer!
    Six weeks later I received from my insurance company an explanation of benefits of its payment to this doctor for his work. The information included this charges or fee, the amount of the check that the insurance company had made to him and this contracted discount from the fee. The check mailed for study of 3 very small tissue samples was in excess of $10,000.
    It took me only one phone to a colleague in Gainesville to confirm that the charges and the check were at least 10-fold too large.
    I called my insurance company and asked “for what services had this doctor submitted a bill.” The employee’s reply ” we can not tell you that; we would be violating this doctor’s privacy if we told you that”. It is my money the company sent.
    I called the doctor to ask the same question. A member of his staff gave a direct answer. “There was a keying error. We billed for 33 biopsies instead of 3. We have already sent a refund.”
    The insurance company should have known 33 samples could not be a correct number. It was no skin of its back; just raise the premiums next year.
    Once I assigned benefits, I was an outcast. The insurer never even told me it received a refund. No matter my income paid the doctor and the insurer.
    Healthcare reform should keep the patient in the loop. The patient should be able to see the doctor’s bill and/or his written record before money changes hands.

  2. Thank you for including this comment. Makes me furious to learn that YOUR insurance company will not tell you what charges were submitted, allegedly in caring for YOU. If in fact the employee gave you the answer s/he has been instructed to give, the company’s policy is unconscionable.
    Thank you for your blog — keep going and sharing your knowledge with us!

    1. All of the insurer’s conduct was outrageous–provider privacy prevents the company from telling patient what services were submitted by the provider, paying for 33 services and never sending me an explanation of benefits for the provider’s refund to my insurer. My money paid the provider and overhead of the insurer.
      As part of its health care reform proposal the US Senate is considering increasing the amount an individual can place into health savings account. What I like about a health savings account is that the patient has some personal responsibility for the final bill. The patient can withhold those dollars if the professional conduct was not professional.
      I am also aware that if an individual has personal money to manage, he manages it carefully; policy makers hope careful management translates into choosing the lowest cost provider and being certain of the benefits of recommended health care procedures. Nancy

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