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Health Care Fraud Questions and AnswersQ: I know other people sometimes cheat a little on insurance claims or allow their doctor to cheat if it results in less out of pocket expense for them. Why shouldn't I? A: People who cheat are a small and criminal minority - - and more and more of these cheaters are being caught. Insurance fraud can jeopardize your employment or cause you to lose your health care coverage. Most importantly, insurance fraud is a crime, and you can face criminal charges for committing fraud. The risk isn't worth it. Q: I noticed an error on a recent bill from my provider. I contacted their billing office and was told the mistake would be corrected. Did I do enough? A: Not always. A medical care provider may adjust a charge on a patient's account but will fail to inform your insurance company about the change in your bill. Let us know if you don't receive an adjusted Explanation of Benefits from BCBSMT with the correct charges. Q: I know my medical care provider is submitting false charges to my insurance company, but I don't want to be the only person pointing a finger at them. What's your advice? A: You should call your insurance company or a law enforcement agency about the fraud. A fraud scheme usually involves a pattern of false billings. If your bills are being falsified, it's likely that charges for other patients are also being falsified. The fraud investigation will identify other patients willing to share information. Current or former employees of the medical care provider can also be used as sources of information. Chances are you're not the only person who knows the story. Q: My doctor charges a lot of money for a routine office visit. Is this fraud? A: By itself, a high price for a service doesn't mean that fraud is involved. Fraud may be involved if the charge is "upcoded". An example of upcoding occurs when a routine service is falsely described and billed as an extensive or complex service. One example of upcoding is when a doctor or other health care provider bills an hour's worth of treatment for a fifteen-minute session. Standard codes have been established and are used throughout the health care industry to describe specific medical services, supplies, and equipment. Call your insurance company if you believe your services are being upcoded. Q: My BCBSMT coverage was cancelled six months ago, but my medical care providers continue to bill BCBSMT for services I am currently receiving. Is this fraud? A: BCBSMT's claim processing system contains specific instructions to deny claims for members if the service is rendered after the coverage was cancelled. Let your providers know that your coverage is not valid, or you will continue to receive denial notices from BCBSMT. If the provider is billing altered dates of service that indicate services were received when the coverage was still effective, then contact our Special Investigation Unit to have them investigate the claims. Q: My medical care provider's statement doesn't give enough information to tell if the charges are accurate. How am I supposed to know if there's fraud involved? A: Ask the provider for a detailed itemization of the charges. If the provider can't or won't give you an itemization, contact your insurance company to have them review the claim. Make sure you actually received everything that was charged. If you suspect the itemization contains false or misleading information, report the situation. |
A Very Frequent QuestionQ: Why would my doctor even think about committing fraud? Aren't people in the medical profession well paid?A: Not all health care fraud is committed by providers. It can also be committed by patients, agents, and others. We're happy to report that the vast majority of providers are honest and ethical. Only a small minority get involved with criminal activity. The driving force behind fraud is typically greed which can affect anyone. |