Fraud is a pervasive problem across all industries, but it can be damaging when it involves healthcare and insurance companies. In healthcare, fraud is any deception that seeks to secure reimbursement for products or services not legitimately provided, thereby raising costs and hurting the patient, provider, and insurer.Â
As highlighted at the Health 2.0 Conference, healthcare fraud is a white-collar crime that has real consequences, not just financial but also personal and professional. Therefore, reviewing the common red flags associated with this kind of criminal activity is essential so that insurers and providers can protect themselves and their customers in 2023.
Identifying Fraud
The US healthcare industry is estimated to lose over $70 billion annually due to fraudulent activities. While the most notorious scams target patients directly, many fraudulent claims and bills also target healthcare insurers. So how can insurers tell when something looks fishy? Here are some of the red flags to watch for.
Unusual Or Abnormal Claims
The most basic way to spot potential fraud is to look for any unusual or abnormal claim. If a claim includes multiple visits, services, or supplies on the same day, this could be a sign of a problem. Another red flag is a claim that doesn’t follow the expected reimbursement pattern, reviews Health 2.0 Conference.
Claims With Questionable Patient Identifiers
Another clue of fraud is a claim that uses the wrong patient identifiers or does not match the identifiers of the person the insurer knows. In addition, claims with nonexistent, inaccurate, or invalid Social Security numbers, addresses, and other personal details can indicate a problem.
Excessive Billing
 In some cases, providers may attempt to increase the amount of the reimbursement they receive fraudulently. Excessive billing is one of the primary methods they use to do this. It may be subtle but can add up over time, resulting in a significant financial loss for the insurer.
Other Unusual Billing Patterns
Another warning sign of fraud, underlined at the Health 2.0 Conference, is billing for procedures, services, or treatments that the patient did not receive or was not qualified to receive. Also, if the same service is billed more than once or the provider charges for multiple visits when only one is necessary, this can be a red flag.
Health 2.0 Conference shares that fraud in the healthcare industry can be challenging and very damaging if not detected promptly. Reviewing the red flags mentioned above and investigating any potentially suspicious activity is essential to keep insurance companies and patients safe from unscrupulous practices. It may take time and effort, but taking steps to protect against fraud can help keep healthcare costs down and ensure the highest possible quality of care.
Tips To Avoid Healthcare Insurance Fraud
Stay Informed
Being informed on the type of health insurance coverage that you have and its associated benefits is critical in protecting against healthcare insurance fraud. Take the time to learn your health plan, and check your explanation of benefits (EOB) when they come in to ensure you recognize any charges. By understanding your policy coverage, it will be easier to spot fraudulent activity.Â
Additionally, taking an active role in managing your healthcare helps protect yourself from fraudulent activities, highlights Health 2.0 Conference. Keep track of any doctor visits, appointments, prescriptions, and procedures, as these could all be potential targets for insurance fraud.
Be Skeptical
Also, Health 2.0 Conference shares that when it comes to potential healthcare fraud, don’t be afraid to question. Suppose you ever receive bills for treatments or procedures that you don’t recognize or understand. In that case, you must contact your insurance provider to review the charges and determine their legitimacy. Paying a fraudulent bill could lead to complications down the road if an audit of your insurance occurs. It’s also a good idea to review any documents you sign at a medical facility and ask questions if you do not understand what is on the document.
Report Fraud
Fraudulent activities in the healthcare industry are on the rise. Reporting suspicious activities are vital to curbing these behaviors and protecting the system. There are several avenues to report any suspicious activity, such as submitting tips directly to the federal government or filing complaints directly with your insurance provider. Filing an online complaint with the federal government helps to give them more information on a particular healthcare provider and assists in their investigations. Health 2.0 Conference highlights that recovering financial losses from insurance fraud may also be possible if the perpetrator is brought to justice.
ConclusionÂ
Taking proactive steps to prevent healthcare insurance fraud is essential for everyone. Reviewing documents, keeping track of healthcare treatments and activities, and understanding insurance plans are all essential steps to staying safe from fraudulent activities. Staying updated with the latest healthcare trends by attending an event in 2023, like the Health 2.0 Conference in the USA and Dubai, will help. Reporting any suspicious activity also helps to ensure the system’s integrity and can provide financial compensation for losses incurred. Everyone can protect themselves from fraud in the healthcare industry, emphasizes Health 2.0 Conference.
