Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
That's the problem. Many people count on their insurance companies to check for billing errors. Insurance companies can't catch them all for several reasons, complicated billing codes and the sheer number of claims, to name a few. Health care fraud is something that ends up costing all of us. It one of the reasons that premiums keep going up and up and up.
Yes, insurance companies make a profit. And that profit is based on the premiums that we pay. Health insurance fraud pushes up the premiums. The point is that fraud is something we all pay for. When your health care provider overcharges you for a service, we all end up paying for it, either through higher premiums or taxes, in the case of Medicare.
Insurance providers pay a lot of money to purchase sophisticated analytic tools to analyze claim and provider data to identify abuse, but they don't catch everything. More people need to call out their doctors for ridiculous billing.
The issue here is not insurance company profits; it is overcharges by health care institutions... doctors’ offices, hospitals, labs, etc. often charge for services not rendered or overcharge for those provided.
Location: Stuck on the East Coast, hoping to head West
4,640 posts, read 11,933,539 times
Reputation: 9885
I work for an insurance company and pay medical claims--have been in this business for years. Most of the fraud that I've seen isn't from doctor's billing for services not rendered. There's a lengthy explanation for this, but suffice it to say that most of the software I've worked with tracks all sort of things about insured members, to the point where the company almost knows what you're next bill's gonna be. Not saying it couldn't happen, but I haven't heard about it happening that much in that scenario. Lately, the fraud that I've been hearing a lot about is insured members "lending" their health insurance cards to their uninsured friends which I suspect could increase given the current state of our healthcare. Incidentally, I've never had to show my driver's license when I've gone to the doctor. I just show my card which has my name and an id number.
The other thing that I have been hearing about is when people go to free screenings. For example, people might go to a free blood pressure or cholesterol check. The company sponsoring this event than collects the personal info of the people who attend and then files bogus claims. In my experience, this is particularly troublesome with Medicare recipients.
Anyway, my advice would be to have providers tighten identification checks when accepting health insurance cards. Maybe have a picture on them like driver's licenses? Also, I really, really wouldn't go to any of the free healthcare screenings unless I was absolutely certain who was sponsoring it and why and what their privacy regs were.
I work for an insurance company and pay medical claims--have been in this business for years. Most of the fraud that I've seen isn't from doctor's billing for services not rendered. There's a lengthy explanation for this, but suffice it to say that most of the software I've worked with tracks all sort of things about insured members, to the point where the company almost knows what you're next bill's gonna be. Not saying it couldn't happen, but I haven't heard about it happening that much in that scenario. Lately, the fraud that I've been hearing a lot about is insured members "lending" their health insurance cards to their uninsured friends which I suspect could increase given the current state of our healthcare. Incidentally, I've never had to show my driver's license when I've gone to the doctor. I just show my card which has my name and an id number.
The other thing that I have been hearing about is when people go to free screenings. For example, people might go to a free blood pressure or cholesterol check. The company sponsoring this event than collects the personal info of the people who attend and then files bogus claims. In my experience, this is particularly troublesome with Medicare recipients.
Anyway, my advice would be to have providers tighten identification checks when accepting health insurance cards. Maybe have a picture on them like driver's licenses? Also, I really, really wouldn't go to any of the free healthcare screenings unless I was absolutely certain who was sponsoring it and why and what their privacy regs were.
Just my 2 cents
You work in medical claims payment? You wouldn't really be exposed to a lot of fraud then unless you worked in the Special Investigations Unit (SIU). It's the people in the SIU department who are responsible for researching fraud referrals -- one's that are phoned in or caught by an automated prepayment or postpayment system. Most large insurance companies use some type of automated prepayment scoring system, so they actually pull the suspicious claims before they even send them to the payment department -- thus, most fraud cases never even reach your desk.
I'm sure that insured members lending their cards to others does count for some fraud (false claims), but on the whole, I would wager that it only counts for a small percentage of fraud. Most fraud comes from the items I mentioned before, stuff like: billing for services never rendered, billing for more complex services to receive higher reimbursements, double billing, billing for packaged items separately, and so on.
As I said before 3-10 percent of EVERY dollar spent on health care goes to fraud -- and I doubt very much "false claims" can account for all of this.
It is VERY IMPORTANT that everyone review their doctor's bills!!! If you suspect fraud, you can report it to your health insurer. By law, if someone reports a suspicious claim, an insurer must investigate it -- the claim goes straight to their SIU department.
When it comes down to an argument between to 'airchair' experts, I think that the discussion usually goes to the person who does it for a living.
Forest, thanks for taking an interest in my thread. You may want to read some of my posts more closely. Looks like there's some information in there you may have missed.
Greenie
Please register to post and access all features of our very popular forum. It is free and quick. Over $68,000 in prizes has already been given out to active posters on our forum. Additional giveaways are planned.
Detailed information about all U.S. cities, counties, and zip codes on our site: City-data.com.
Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
