In 2019 the U.S. spent $3.8 trillion on health care. That much money makes health care ripe for fraud. A conservative estimate by The National Health Care Anti-Fraud Association sets health care fraud at 3% of total health care expenditures. That’s $114 billion.
As a health care consumer, you could be the target of fraud. I’ll explain how you can protect yourself. But let’s start out by understanding exactly what health care fraud is.
What is Health Care Fraud
Fraud is a deliberate, dishonest act to receive payments or medical benefits the person isn’t entitled to receive. In other words, it’s not a mistake. Rather, fraud is knowingly doing something wrong.
Health care fraud is a felony. The stakes are high to cover their tracks. Therefore, scammers will likely be as stealth as possible. That means potential victims need to be vigilant about protecting themselves.
Victims of Health Care Fraud
The health care industry is made up of a lot of people and businesses. There are patients, providers, insurance companies, medical equipment companies, and drug companies. They can all be victims. Or, there can be people in their midst who commit fraud.
And that takes me to the heart of this post. How do you, as a patient or health care consumer, protect yourself from fraud. The first thing to know is where you’re most likely to find evidence of fraud. Let’s start with medical billing.
Medical Billing Fraud
Where it Happens
Medical billing is complicated. There are thousands of Current Procedural Terminology (CPT) codes – a code for every medical, surgical and diagnostic service or procedure. Each code represents a charge on your bill. The complexity of billing and large number of codes makes this an inviting place for fraud. Here are common fraudulent billing practices:
- Double billing
- You are charged twice on the same bill or separate bills for the same service.
- Billing for services you didn’t receive
- This could be a big or small item sandwiched in between legitimate services on your bill.
- Unnecessary services
- For example, the doctor used an incorrect or exaggerated diagnosis code in order to run high-cost, unnecessary tests or procedures.
- Unbundling services
- Bundled services are two or more services grouped together for one charge. Unbundling is separately billing bundled services.
How to Protect Yourself
Carefully review your itemized medical bills and Explanation of Benefits (EOBs) from your insurance company. Check these items for accuracy:
- Date of service
- If you keep a calendar of your appointments, check those dates against the dates on your bill. They need to match.
- Services delivered
- You are charged only for the services you received.
- Duplicate charges
- Make sure a service or procedure that was performed once doesn’t show up twice on the same bill or again on a separate bill.
- Unbundled services
- Incorrect diagnosis
- Your diagnosis code, or ICD (International Classification of Diseases), is listed on your bill and EOB. Google the code to find the diagnosis used for your bill. Make sure the diagnosis isn’t exaggerated (or just plain false) to justify additional charges. For example, if you fell and went to the doctor with a sore wrist, the diagnosis should not be for a head trauma due to a fall.
Identity Theft
What it is
Medical identity theft happens when people steal your personal information in order to get medical care. Your Social Security number, insurance plan number, or Medicare number are all targets for theft.
Scammers have perfected sounding legitimate when calling to ask for personal information. For example, they sound like someone from your doctor’s office. The caller says she is trying to get your insurance claim processed, but just can’t quite read your insurance account number. If you’ll give that number to her, she’ll get this taken care of for you. Don’t do it!! If you think the call might be legitimate, call your doctor’s office and speak with the billing office.
How to Protect Yourself
Here are three ways you can protect your identity:
- Never share your personal information (insurance plan number, Medicare number, Social Security number) over the phone or with anyone you don’t know and trust.
- Do not accept any “free” services, money or gifts in exchange for providing your personal information.
- Do not pay your bills over the phone.
The Federal Trade Commission has a webpage dedicated to protecting your information, how to spot potential theft, and what to do if it happens to you.
If You Suspect Health Care Fraud
If your medical bill doesn’t look correct, call your provider. Ask for an explanation. Remember, fraud means someone knowingly tried to get money or benefits they weren’t entitled to. That’s different than a mistake. Give your provider a chance to explain what appears to be an error. They may be able to explain the charges or will correct an error.
Your insurance provider should be notified of any potential fraud. If you have Medicare, call 1-800-MEDICARE (1-800-633-4227).
In addition, the FBI investigates and prosecutes health care fraud. You can complete an online fraud report using the FBI’s Electronic Tip form.
Fraud can occur even when we’re vigilant. But by taking these steps to protect your information and confirm the accuracy of your medical bills will help stop you from becoming a victim of health care fraud.