Identifying Health Care Fraud

False Claims

False claims can be created by policy holders or medical care providers. The suspect deliberately submits false information to an insurer to obtain reimbursement on a claim or series of claims. False claims can include the following:

1. Billing for services not received.


2. Misrepresentation of services. This usually involves billing for a more complex procedure to receive higher reimbursement.


3. Misrepresentation of the service date(s). This may be done to receive benefits for services rendered to a patient during a period they were not covered.


4. Misrepresentation of the patient's condition. This usually involves billing a non-covered condition with a covered diagnosis code.


5. Misrepresentation of the charge for a service. This can be accomplished by not reporting discounts given to the patient, or by physically altering the charge on a claim to be greater than what the provider actually charged.


6. Misrepresentation of identity. The identity of a patient or provider can be changed in this scheme. A patient's identity may be misrepresented to cover services for a patient without coverage under a person's name who does have coverage. A provider's identity may be misrepresented to obtain or increase benefits that may not have been available otherwise.

Falsifying Other Insurance Related Information

1. Applications for coverage. The intentional omission or misrepresentation of information (including previous medical treatment) on an application could be considered fraudulent.


2. Accident reports. This usually involves providing false information to increase reimbursement under a contract's accident benefit.


3. Coordination of Benefits. This may involve withholding information about another insurance coverage in an effort to obtain duplicate payments.

Eligibility Fraud

Eligibility fraud is often a misrepresentation made by a group, an individual, an agent, or a combination of these entities.

1. Group Fraud This usually involves a misrepresentation to obtain coverage for a non-employee, by representing them as an employee of the group.


2. Individual Fraud This could happen if someone living outside Montana misrepresented their residency to obtain or maintain coverage under a BCBSMT individual product.


3. Agent Fraud. This can involve the sale of nonexistent policies, misrepresentation of information to the insurer (BCBSMT), alteration of documents, etc.