Healthcare insurance is generally outside the purview of property insurance. Still, it affects all types of casualty insurance coverage, such as medical care components, including medical payments for auto accident victims or workers injured in the workplace. Healthcare insurance fraud is a criminal act involving obtaining financial gain from an insurer or insured using misrepresentation of facts or pretenses.
Corrupt Medical Billing Services
Medicaid and Medicare have guidelines that demand that reimbursement be made for the procedures that are medically performed. However, given the available loopholes, unethical medical billing services practices for treatment that were never given to the patient are often used as a method of billing fraudulently to health insurers. The providers can falsify the signature of persons enrolled in Medicare to make claims. Others use bribes or kickbacks for corrupt medical billing services. Some doctors claim reimbursement from the insurers for services not rendered to the patients. In contrast, others instruct patients to undergo unnecessary procedures and argue for the benefits from the healthcare insurer.
Alteration of Information
Cases of changing or modifying documents to deceive healthcare insurers have also been experienced. In this type of fraud, the healthcare provider falsely diagnoses patients to order these additional tests and collect them through the billing process. The same thing can happen with treatments because specific treatments are unlikely to be approved and not paid unless a diagnosis is made first.
There are bills for a particular group of services covered by a single comprehensive code, but some physicians provide billing codes for multiple procedures for each service provided. These services would typically cost less if bundled together.
Emergency Cases as a Source of Loopholes
Emergency cases are also loopholes for fraud schemes. It is a rule that emergency cases be attended to immediately. In some situations, the patients find themselves admitted to facilities that their insurers ate not contracted with it. The insurer is obligated to cover all emergency cases, and different hospitals have different rates for similar services or procedures. Therefore, determining the payment rate for the services between the insurer and the provider results in great misunderstandings. As a result, a mediator is called upon to help in finding solutions. Hiring a mediator is costly.
Proposed Way Forward
Gregory Pimstone of Manatt recommends that the insurers motivate their employees by providing salaries on time motivations to monitor and detect fraud schemes against them. The patients are to be informed of the fraud schemes, and the perpetrators are to be punished severely.