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wiseGEEK: What is Medical Insurance Fraud?

Every year, billions of medical insurance claims are processed by healthcare providers and individuals to cover the costs of medical care. However, in some cases, criminals try to mislead the insurance firms for financial benefit. The act of intentionally attempting to deceive or falsify medical insurance claims in an attempt to gain more money from a medical insurance company is considered medical insurance fraud.

With the costs of healthcare reaching astronomical levels worldwide, entities that commit medical insurance fraud are a significant part of the problem. When a healthcare provider or insurance company has to spend additional time sorting out possible fraud, the costs of staffing and administration goes up, and medical costs rise as a result. The people who commit insurance fraud end up hurting others as a result of this illegal behavior.

In addition to causing healthcare costs to increase, medical insurance fraud results in claims taking longer to process. This can delay medical care for people who need it the most. For example, if a patient is awaiting approval from an insurance company for a specific surgical procedure, it may take days or even weeks longer to get approved. This may cost the patient additional suffering, or the patient might even die while waiting for treatment.

The three most common forms of medical insurance fraud are false claim filing, false personal injury claims, and excessive treatments. The insurance fraud may originate with the individual

attempting to “fake” an injury in order to receive benefits, or the healthcare provider may be the liable party. In either case, medical insurance fraud is a crime that is punishable in most regions.

False or excessive claim filling occurs when a healthcare provider attempts to bill the insurance company for a service that was not actually performed. The provider may attempt to bill the insurance company for equipment and supplies that were not used, or which may be determined to be excessive given the nature of the service. This causes the claim to increase and can also cost the patient an additional fee.

Personal injury claims supported by “personal injury mills,” which are lawyers who benefit from exaggerating the actual injury of the victim, cost the medical insurance industry millions each year. In some cases, the victim falsifies his injuries in order to receive benefits. This type of medical insurance fraud may take years to sort out, and it burdens the legal system as well as the medical insurance industry.

It is estimated that in the US alone, money lost to insurance fraud accounts for billions of US Dollars each year. Medical insurance fraud can be prevented by careful and accurate evaluation, recording, and billing of medical treatment by healthcare providers. It is up to healthcare providers, consumers, and insurance firms to work together to prevent this costly and damaging form of fraud.

Category: Insurance

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