False Medical Claims

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CONTENT PROVIDED BY THE NEW YORK ALLIANCE AGAINST INSURANCE FRAUD

Health care scams cost Americans billions of dollars each year. Taxpayer-funded programs such as Medicare, Medicaid and others are among the biggest victims. This makes health-care fraud one of America’s largest taxpayer rip-offs.

Organized crime rings hatch many schemes. Hospital chains, individual employees and even patients can be involved — as victims or perpetrators.

THE SCAMS

Phantom treatments. Dishonest medical providers will bill health insurers for expensive treatments, tests or equipment you never received – and for illnesses or injuries you don’t even have.

Double billing. Unethical providers may double- or triple-bill health insurers for the same treatments, hoping the insurer won’t discover the overruns in the big stack of bills.

Shoddy care. You might receive shoddy or substandard treatment for real and urgent medical problems. One eye doctor shined pen lights into patients’ eyes and said he’d performed cataract surgery. Surgeons have used defective pacemakers and catheters during heart surgeries, which have killed patients or required more surgeries to correct the problems.

Unneeded care. You might receive dangerous and even life-threatening treatment you don’t need. One surgeon performed heart surgery on patients who didn’t need it.

Bogus insurers. Insurance agents or brokers sell you low-cost health coverage from fake insurance companies. Then they take your premiums and disappear. You’re left without vital health coverage, and don’t even know it until you make a claim.

Identity theft. Cheaters steal your medical ID number, then use it to bill health programs tens of thousands of dollars for phantom treatment. Crooks steal your health info from dumpsters behind medical clinics, break into doctor offices and steal files, and hack into computer databases containing your records.

Rolling labs. Mobile diagnostic labs give needless or fake tests or physical exams to consumers, then bill health insurers for expensive procedures.

  1. A person hired by a medical provider to drum up business trolls through neighborhoods, often low-income areas, enticing people to come to a clinic for tests. These runners will even round up children for unneeded tests and procedures.

THE PRICE YOU PAY

Coverage drained. Your coverage limits might be drained by worthless and unnecessary treatments.

Financial disaster. Inflated or phantom medical bills can increase your co-payment, beyond your ability to pay. This could force you into collections and damage your credit rating. And if you bought health insurance that ends up completely fake, you could face financial disaster if you must pay large medical bills with your life savings because your policy’s worthless.

False medical record. Your medical record contains false information about illnesses, diseases, injuries or other problems you never had. Your information is available to insurers, so you could be denied health coverage or pay higher premiums because of a trumped-up medical record.

Premiums rise. Your health premiums rise because insurers pass the cost of fraud onto policyholders. High health premiums discourage employers from offering this needed employee benefit.

Personal distress. You receive bogus or needless treatments that are painful, distressing, can threaten your health — and even kill you.

Taxpayer rip-off. Billions of your tax dollars pay for fraudulent claims against Medicare, Medicaid and other taxpayer-funded health programs every year. These are your tax dollars being stolen.

FIGHT BACK

• Keep detailed records of treatments you receive. Include all dates, locations, who provided the treatments, what services you received, and what medicine, supplies or equipment were provided.

• Carefully review the billing and summary statements you receive after treatment. Are the treatment dates, doctor name(s), facility locations and medical services the same as you remember? Know what medical equipment and supplies your provider ordered, as well.

• Never sign blank insurance claim forms.

• Ask your medical providers what price they charge, and what you’ll pay out-of-pocket.

• Avoid door-to-door or telephone salespeople who offer you free medical services or equipment.

• Never give strangers your policy number, insurance ID number, Medicare claim number or other info, especially if they offer you cash or free gifts, treatments or equipment.

• Know what your medical benefits are — what’s covered and what isn’t.

• Back off if someone says they can bill your health program to pay for an uncovered treatment or equipment. You’re being pulled into an illegal scheme. You could lose your health coverage, be arrested, fined, thrown into jail, and live with a conviction record that disrupts your life for years to come.

• Never pay your health premiums in cash, and be wary if the health insurer asks you to pay a full year’s premium upfront.

• Be careful if medical providers say they’re connected with the federal government, Medicare, Medicaid or other health programs.

• Back off if the insurer offers you health coverage for “just pennies a day,” or sells coverage at a price far lower than others.

• Check with your state insurance department to make sure the health insurance company is licensed to do business in your state.

• See if the health insurer has a history of consumer complaints, bankruptcy, fraud convictions or other problems. Your state insurance department and consumer protection agency, and Better Business Bureau are good places to start.

WHO TO CONTACT

If you think you’ve discovered a healthcare scam, contact:

• The insurer that paid the claim (the name, address and phone are on the explanation of benefits you receive in the mail).

• If you think the scam victimizes Medicare, Medicaid or another public health program:

Phone/Write: the U.S. Department of Health and Human Services toll-free: 1-800-HHS-TIPS (1-800-447-8477)

Office of Inspector General

Department of Health and Human Services

ATTN: HOTLINE

330 Independence Ave., SW

Washington, DC 20201

Fax: 1-800-223-8164

e-mail: HTIPS@os.dhhs.gov

 

• Contact your state fraud bureau.

BE PREPARED

Make sure you include this information when you contact the authorities:

• provider’s name and identifying number

• item or service you’re questioning

• date(s) you supposedly received the item or service

• amount approved and paid

• date of the explanation of benefits

• name and Medicare number of the person who supposedly received the item or service

• why you believe Medicare shouldn’t have paid

• other information that might be helpful.