Medical Insurance Fraud

Medical insurance fraud is on the rise. We all pay the cost - estimated at many billions of dollars per year. Medical insurance fraud comes in all shapes and sizes. It's perpetrated by patients, medical providers, or insurance company insiders. 

The biggest offenders are clinics that submit millions of dollars worth of fraudulent or exaggerated claims to insurance companies. Some of these clinics never see a real patient; they just steal identities and submit claims for people who have never been treated.

Some clinics bill insurance companies for seeing patients who have long since died.

Dishonest doctors (or non-professional clinic owners who are not bound by the Hippocratic oath) treat the health care system like its the goose that laid the golden egg. Their schemes involve up-coding, unbundling, billing for treatment not rendered and/or tests that have no useful value for the injury or illness being treated. Sometimes they treat when there is no existing injury or illness. They involve themselves in kickback schemes with durable medical equipment providers and/or prescription medicines.

Patients MUST review their billing to confirm that the treatment billed was the treatment they received. If your health care provider does not provide you with a copy of your billing, request a copy. Review it carefully and, if you find charges for care you did not receive demand it be removed from the bill and notify your insurance carrier. Check out our pages on CPT Codes and ICD-9 Codes. These will take the mystery out the charges listed on your bill.

Our own Diana has her own experience. Her son required some dental work that involved anesthesia. She took him to the dentist where they waited approximately 15 minutes for him to be called. She waited less than 30 minutes for the procedure to be completed. He was still in the chair, when she was called back to his room, the nurse was attending him and he was too groggy to yet walk. It took about 15 minutes for him to get it together enough to scoot over into the wheelchair.

When the bill came, it included a charge for an additional 15 minutes of anesthesia ($200), over an above the 30 minutes also billed. Diana reviewed the bill and after much searching on the Internet found the description of the dental billing code. The description required that the dentist was REQUIRED to be in attendance after the anesthesia had been administered. Based on the time her son was actually in the dentist's chair, it was not possible for him to have received the third dosage and had it been given, the dentist, not an attending nurse, should have been in the room when Diana entered.

It took two phone calls arguing with the billing clerk and demanding to speak to the dentist before the charge was removed from the billing.

Keep in mind when dealing with billing clerks that they are not necessarily CPT Code experts. The experts require a degree in coding! If you want to check out the coding on your bill, you'll find links to CPT Codes and ICD-9 Codes (used for coding a diagnosis) in our TOOLBOX section.

The cost of your premium each month is tied to the cost of health care. Don't think, "The insurance company is paying for it, so why should I care?" YOU are paying for it!

Then, of course, there are the horror stories of individuals with little or no medical training who claim to be a licensed doctor and actually TREAT PATIENTS.

If you'd like to confirm the licensing or determine if there are any disciplinary actions involving your health care provider, click TOOLBOX for links to help you determine this information. There are also links for reporting health care providers, if you think their billing is more than a simple mistake.

Fight Fraud America!