Studies show that over 30 billion dollars is lost each year to health care fraud in the United States. In order to control costs, insurance companies have found it necessary to investigate fraud for the benefits of the members.
Fraud can be committed by both a member and a provider. Member fraud consists of ineligible members and/or dependents, alterations on enrollment forms, concealing pre-existing conditions, failure to report other coverage, prescription drug fraud, and failure to disclose claims that were a result of a work related injury. Provider fraud consists of claims submitted by bogus physicians, billing for services not rendered, billing for higher level of services, diagnosis or treatments that are outside the scope of practice, alterations on claims submissions, and providing services while under suspension or when license have been revoked.
In response to the increased amount of health care fraud in the United States, Congress, through the Health Insurance Portability & Accountability Act of 1996 (HIPAA), have specifically established health care fraud as a federal criminal offense with punishment of up to 10 years of prison in addition to significant financial penalties.
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External links
- HealthDecisions.org - A great source for materials about health insurance, with a thorough learning center for health insurance education and resources.