Ways that Medical Practices Get Caught for Insurance Fraud


How do medical practices get caught for insurance fraud? Antonio D., Fairfax


A shady medical practice would get caught committing the crime of insurance fraud the same way anyone else would get caught; the provider or office staff makes a mistake. A quick internet news search on any given day will bring up at least one story about a medical practice getting caught for fraudulent billing, the most common form of medical fraud. This fraudulent billing isn’t caught because the insurance company is scouring every single line of every single bill, but because there is some glaring mistake.

(Okay, the insurance company might indeed be doing that, but it is for the reasonableness of the charge, not to determine whether or not the treatment actually took place. That is a whole different topic.)

It is estimated that most insurance fraud never gets caught, but repeat offenders do get caught because eventually they mess up. Perhaps the medical records for the date on the bill describe treatment other than what is on the bill, or perhaps there are no medical records at all for that date of alleged treatment. Perhaps an insurance adjuster happens to ask an injured person about treatment on a certain date; the injured person says that they didn’t actually get treatment on that date, or perhaps did, but just not the sort of treatment that is on the bill. Perhaps it is something as simple as billing for treatment on a Sunday or a holiday when the medical practice was not open. Any of these things can raise a red flag to the insurance adjuster and an investigation into the practice starts from there.

If the medical provider’s business address is non-existent or leads to an empty building, there will be a fraud investigation. Really, address verification is such an easy thing to do with internet tools these days. Tax identification numbers and treatment certifications are also very also to verify. There is no excuse for a medical provider to make such a mistake.

If the medical provider’s billing department simply made a mistake, or is using old or out-of-date billing codes, and is willing to fix it, the insurance company may just let it go. If a medical provider has one bill reviewed for possible misrepresentation, it is likely that more of their bills will be reviewed. If it appears that there is a pattern of “mistakes” or misrepresentations, the insurance company will continue to dig.

This article is approved for informational purposes and is not intended to take the place of competent local legal counsel.

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