Medical Insurance Fraud Cases: Investigation & Prosecution

Are you spending large sums of money on your medical coverage? Are you worried about the ever-increasing premiums? Is medical insurance draining you of your savings? If these issues bother you then perhaps, it is time to be aware and get informed of the problem called medical insurance fraud.

A large part of the insurance fraud is committed in the health care sector where individuals and health providers engage in claiming benefits that they are not rightfully entitled to.

According to the medical insurance fraud statistics revealed by the National Health Care Anti-Fraud Association, 2008 the U.S spends more than $2 trillion on healthcare annually. At least 3 percent of that spending — or $68 billion — is lost to fraud each year. The result is soaring figures in medical insurance fraud cases.

The many facets of medical insurance fraud cases are;

• Phantom Billing or billing for services not rendered
  
• Up coding or upgrading or billing for more expensive treatments than those actually provided
  
• Ganging or billing for members who accompanied the patient but were not provided any services.
  
• Inappropriate testing and scheduling visits not needed.

Medical Insurance Fraud Investigation

So what is being done to combat fraud and penalise the fraudsters?
Medical Insurance companies have their own medical insurance fraud investigators who handle claims in which the company may suspect fraudulent or criminal activity, such as falsified claims, staged accidents, or unnecessary medical treatments. They work in the following way;

1.Medical Insurance Fraud investigators gather background information of claimants and witnesses from the database.
2.They access personal information of claimants and witnesses like social security numbers, addresses, and phone numbers and so on to search for any history of insurance fraud.
3.Investigators may make personal visits to claimants and witnesses for any gathering information.
4. Investigators often undertake surveillance work to bring out facts about any claims.
Medical Insurance Fraud Investigators require specialized training and in many cases, a certification is also mandatory.

The National Health Care Anti-Fraud Association, a public private partnership against health care fraud, provides training and education in the field of fraud management. Its association has been operating for more than 25 years with the mission of increasing awareness and improving the detection, investigation, civil and criminal prosecution and prevention of heath care fraud.

Medical Insurance Fraud Penalities

In response to the increased amount of health care fraud in the United States, Congress, through the Health Insurance Portability and Accountability Act of 1996 (HIPAA), has specifically established health care fraud as a federal criminal offense with punishment of up to ten years of prison in addition to significant financial penalties.
If a person is proved guilty of committing fraud, then that individual is subjected to medical insurance fraud penalties which may include one or more of the following;

• Imprisonment
  
• Fine
  
• Probation
  
• Parole
  
• Reconstitution
  
• Community Service

As consumers and members of the community, it is our duty to do everything it takes to help the appropriate authorities to locate, investigate and penalise the perpetrators of this crime. Remember, concealing a crime is same as committing one!