People are always trying to beat the system, no matter what system it is, and healthcare coverage is no different. There are several different ways in which people can commit fraud against their healthcare insurance – this includes both doctors and patients.
It’s a good idea to know about the different types of health insurance frauds, so that you don’t make these mistakes yourself. It also helps that you can recognize when someone else is committing these types of frauds:
When multiple services are taken together, they often cost less because they were paid for in a bundle. Unbundling fraud is when someone submits claims separately, thus making each individual item worth more so they can receive higher returns from the healthcare insurance or government.
This requires falsifying the dates on the invoices and the amounts charged. It is fraud to falsify any information made on a claim, so even if someone were to try to justify it by saying that it would have technically cost that much, it is still fraud.
2. Claiming undelivered services
If a service is covered by healthcare insurance, and the user does not need this service, or does not use all of the coverage amount offered by the insurance provider, they are not at liberty to submit falsified service invoices in order to receive that amount. It is important to remember that individuals are not owed the amount they are covered for unless they actually require those services.
3. Claiming services multiple times
Submitting claims to multiple insurance companies is also fraudulent. Again, just because someone is covered by more than one company, does not mean they are entitled to the full amounts those companies offer. Many companies will indicate what to do if you are covered by more than one company.
Usually, the primary company will cover a certain percentage, and the secondary company will cover another percentage, up to a total of 100 per cent, but never more. These health insurance frauds occur when a person acts as though both companies are the only or the primary company, especially if the individual is ultimately paid more than 100 per cent of the total amount they originally paid out of pocket.
4. Claiming excessive amounts of services
Most healthcare insurance companies only cover a certain percentage of the cost of a service – for instance, 50 or 80 per cent are fairly common amounts, depending on the service. Due to this, some people believe they can falsify a record to cost more, so that they can receive more than that percentage back. This is also considered health insurance fraud, because the amount claimed is falsified.
5. Claiming unnecessary services
Providing medically unnecessary treatments is one of the most common types of health insurance frauds that often occurs. This is most frequently done by doctors in order to try to claim more money from the government. It is fraudulent to provide any service to a patient who does not medically require that service.
A similar type of thing that patients do, which is not technically fraud, but which is taking advantage of the system is to lump many services together in one year to take advantage of their insurance, even if they don’t require that service yet.
6. Claiming a higher amount than paid
Individuals trying to claim a higher amount than what was actually paid in order to get a higher reimbursement is another fraudulent act. People may try to justify this act because they still have a certain amount of money left to claim for the year, but that isn’t how the insurance system works.
7. Claiming services for someone who didn’t receive them
When more than one person is covered under a healthcare plan, each service claimed must be claimed under the correct person’s name. If the claimant has used up all of their allowed reimbursements for a certain service, they may not claim the expense under the name of another claimant on the plan. These health insurance frauds are easily detected after a private investigation.
8. Claiming products or services for someone not covered by the plan
It is also fraudulent to submit a claim under your own healthcare insurance for a friend or family member who is not covered under your plan. This would essentially require the claimant to somehow falsify the information of who received the services.
9. Claiming expenses for not covered products or services
Some people also try to claim that they received a product or service that is covered when they actually received one that is not covered, or that is covered for more than what they actually received.
For instance, if a person received a service covered at 50 percent, but claimed it under a service which is covered at 70 per cent this would be fraudulent. As well, someone claiming they received prescription glasses when they simply bought a cool new pair of sunglasses for the summer would also be committing fraud.