Medical Insurance Fraud

Medical insurance fraud is probably happening more often that we are aware of or care about unless it directly affects us. I visited a doctor about two years ago and the nightmare of visiting this physician only once is still chasing me from time to time. I should have known better when he warned me on my first and only visit to his office that he has other patients with my exact unusual last name and sometimes "they make errors with patient medical files". Soon after I left his office with this dire warning, I started receiving insurance benefit statements from my health insurance company. The insurance claims reported ear surgeries and other practices which I never received. After a few calls to the doctor’s office and speaking to multiple office administrators about the incorrect invoices I have received for the services I had never received, my calls were ignored and subsequently I reported my medical insurance fraud case to the insurance company which investigated the physician and cleared me of all charges. Following the investigation, the doctor’s office sent me a zero balance statement to confirm the resolution of my case.

Fast forward two years later, I have just received a brand new statement from the doctor’s office with all previous amounts as "past due" plus new charges for new visits I have never made. Considering my options, I can burn the statement and ignore the charges, call their office and complain again, or contact the medical board regarding this blunt medical insurance fraud which I am strongly considering. This time I don’t even have the insurance company on my side since I have switched insurance carriers a long time ago and I basically find myself alone against this doctor and his fraudulent practices. Even if this is just a case of careless insurance paperwork processing and not a planned and widespread medical insurance fraud, it is still not acceptable to me as it is time consuming to address the same issue over and over again and can impact the credit score if this doctor submits my account to a collection agency.

Although the case I just described is somewhat unique because most medical fraud cases are intended to defraud the insurance company and not the patient because that’s where the easy money is, there are many ways that we can monitor and detect medical insurance fraud which we should strongly consider because not only doctors can commit medical insurance fraud and must be stopped but also medical identity theft is highly probable especially during difficult economic times. If fraudulent medical insurance transactions are not detected timely, they can have negative consequences including reduced credit score, collection agency calls, and inability to apply for credit due to negative comments in credit reports. There is also a critical non-financial consequence which can be deadly and it is the comingling of medical records. You see, when medical identity theft or insurance fraud is committed, the medical records at the insurance company as well as the doctor’s office are modified to include erroneous information about the patient and the medical history. As such, all future medical decisions can be based on recorded medical transactions whether accurate or not.

Consider the following steps to monitor and detect erroneous or fraudulent medical insurance transactions:

1. Review your credit reports regularly to look for unknown debts especially related to medical expenses. If you notice a medical debt transaction that you do not recognize, contact the medical service provider to inquire about the transaction and correct the reported debt. If you are unable to contact the doctor’s office or resolve the issue with their office and still believe that you may be a victim of medical identity theft or medical insurance fraud, file an identity theft report with the police and contact your heath insurance company as well as the credit reporting agency where you have detected the transaction.

2. Review your medical benefit statements when you receive them. Usually, after medical services are performed and medical claims are filed, the health insurance company sends out an insurance benefit statement listing the medical services you have received, physician charges, expenses covered by the insurance and your out of pocket costs. If any of services are not yours, contact the health insurance company immediately to open a medical fraud investigation case.

3. Request and review all the payments that your health insurance company has made for the medical services that you have received for a given period. This practice will help you detect any payments that have been made under your name for services which you do not recognize. Preferably, this review should be performed annually for services provided and payments made during the year.

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