Insurance Fraud – A Major Concern to Reckon With

by | Last updated on Sep 11, 2023 | Published on Jul 28, 2014 | Medical Record Review

Healthcare fraud is a major concern indeed for individuals as well as private/government employers. While individuals who are preys of healthcare fraud are taken advantage of and subjected to unnecessary medical treatments that may ultimately prove dangerous, government as well as private employers end up paying for services that are not actually required. This increases their cost of providing insurance benefits to employees, and thereby the overall cost.

A patient’s medical records contain sensitive information that needs to be kept confidentially at all costs. However, a few dishonest providers make illegal use of these details for their own selfish interests. Healthcare fraud has many faces:

  • Genuine patient information may be used to bill for services that were not provided at all.
  • Up-coding or falsely billing for a higher-priced treatment than what was actually provided.
  • Performing services that are medically unnecessary just for the purpose of securing insurance payments.
  • Misrepresenting a patient’s diagnosis to account for surgeries, tests and procedures that are not medically necessary.
  • Reporting treatments that are not covered as medically necessary covered treatments.
  • Billing bundled procedures as separate procedures.
  • Waiving patient deductibles/co-pays for medical/dental care and overbilling the insurance payer or healthcare plan.
  • Billing a patient more than the co-pay amount for services that were paid in full by the benefit plan under a managed care contract.

Usually, fraudulent claims are revealed in a comprehensive medical record review. For attorneys handling cases related to insurance fraud, personal injury etc; organization and summarization of the relevant medical records are important processes that reveal the actual facts of a claim.

Healthcare fraud must necessarily be exposed and necessary action taken to prevent its recurrence. It is a grave crime that has negative consequences for everyone involved, and therefore insurers, government, healthcare providers, and patients cannot afford to ignore it.

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