Jeffrey Wade
Healthcare fraud is a federal crime that involves intentional deceit for illicit gains. It includes a range of deceptive practices, such as double billing, phantom billing, and upcoding, which result in patients being charged for services they did not receive or for more expensive services than they actually received. Patients should be cautious of individuals recommending specific doctors, as they may be runners receiving compensation for referrals. They should also be wary of free services, as these could be fraudulently charged to their insurance company. If you suspect healthcare fraud, you can report it to your local company or relevant federal agencies, such as the FBI's Internet Crime Complaint Center (IC3) or the OIG Hotline Operations, which handles complaints about fraud in the U.S. Department of Health and Human Services' programs.
| Characteristics | Values |
|---|---|
| Reporting authority | National Insurance Crime Bureau, FBI's Internet Crime Complaint Center (IC3), Office of Inspector General (OIG) Hotline Operations, Blue Cross Blue Shield (BCBS) |
| Types of fraud | Double billing, phantom billing, unbundling, upcoding, bogus marketing, identity theft, impersonating a healthcare professional, diversion, doctor shopping, unnecessary treatment, unlawful MRI scans, prescription fraud |
| Preventive measures | Be cautious of individuals recommending specific doctors, do your research on doctors, get a second opinion, maintain records of visits and treatments, safeguard your insurance information, check your explanation of benefits (EOB), review your statement, ask your doctor to explain services, report discrepancies, beware of "free" services, block robocall numbers |
| Reporting process | Reports can be made anonymously, online, or by calling the number on the back of your member identification card |
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What You'll Learn
- Recognising insurance fraud: beware of free services, “runners”, and phantom billing
- Where to report a doctor for insurance fraud: contact your local Blue Cross Blue Shield company, or submit a complaint to the FBI's IC3?
- Protecting your insurance information: treat it like a credit card, and don't give it to marketers or solicitors
- Reporting process: each report is important, but not every submission results in an investigation
- Examples of insurance fraud: double billing, unbundling, upcoding, and bogus marketing
Recognising insurance fraud: beware of free services, “runners”, and phantom billing
Recognising insurance fraud and knowing how to report it is important to protect yourself and your insurance company from financial loss. Here are some key things to look out for:
Beware of "Free" Services
Be cautious if you are asked to provide your health insurance information in exchange for a "free" service. This is often a scam, and your insurance company could be fraudulently charged. Always check your explanation of benefits (EOB) to ensure that the dates, locations, and services billed match what you received. Contact your insurance provider immediately if you spot any discrepancies.
Runners
"Runners" are individuals who recommend specific doctors or attorneys and receive compensation for referrals. If you are referred to a particular doctor or attorney, be wary and do your research. This is a common sign of a "medical mill" operation, where patients are funneled through a system to generate profits, often with unnecessary treatments.
Phantom Billing
Phantom billing occurs when you are billed for a service visit or supplies that you never received. Always review your EOB and report any discrepancies. This type of fraud can also occur when a provider bills for more expensive services than what was actually provided, known as "upcoding."
To report suspected insurance fraud, you can contact your insurance provider directly and file a complaint. Additionally, organisations like the National Insurance Crime Bureau and the FBI's Internet Crime Complaint Center (IC3) provide resources and accept reports of insurance fraud.
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Where to report a doctor for insurance fraud: contact your local Blue Cross Blue Shield company, or submit a complaint to the FBI's IC3
If you suspect a doctor of insurance fraud, you can report it to your local Blue Cross Blue Shield (BCBS) company. BCBS companies partner with state and federal agencies and advocacy organizations to report, investigate, and reduce health care fraud. You can call the number on the back of your member identification card to report fraud. If you are not a BCBS member, you can call the report fraud hotline at 1-877-327-2583. Federal employees or retirees can report potential healthcare fraud by calling 1-800-337-8440.
Alternatively, you can submit a complaint to the FBI's Internet Crime Complaint Center (IC3). IC3 is the main intake form for a variety of complaints, from cyber-enabled fraud and scams to cybercrime. IC3 shares reports of crime with its network of FBI field offices and law enforcement partners, strengthening the collective response to such crimes. You can submit a report on the IC3 website, but be aware that due to the high volume of complaints received, IC3 may not respond directly to every submission.
You can also report healthcare fraud to Blue Shield of California (BSCA). BSCA established the Special Investigations Unit to combat healthcare fraud and abuse, and the department works with anti-fraud efforts in the industry, as well as federal, state, regulatory agencies, and local authorities. You can call the BSCA hotline at (855) 296-9092, which is manned 24/7, or submit a report online at www.blueshieldca.com/fraud-report. You may choose to remain anonymous or include your contact information.
Additionally, the Office of Inspector General (OIG) Hotline Operations accepts tips and complaints about potential fraud, waste, abuse, and mismanagement in the U.S. Department of Health and Human Services' programs. You can start your online complaint with HHS-OIG by visiting their website.
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Protecting your insurance information: treat it like a credit card, and don't give it to marketers or solicitors
To protect your insurance information, it is important to treat it with the same level of care and caution as you would your credit card information. Here are some key steps to follow:
Be cautious about sharing your insurance information
Do not give your insurance information to marketers or solicitors. Be wary of anyone asking for your insurance details, especially if they are offering “free” services or products. Always verify the legitimacy of the requester and never provide your information to unsolicited callers or unknown websites.
Secure your digital privacy
Avoid posting personal information on social media, such as your home address or birthday. Adjust your privacy settings to limit the exposure of your data. Be cautious about the websites you visit, the emails you open, and the advertisements you click on. Data miners and insurers may use this information to create a profile about you, which could affect your insurance premiums or be sold to third parties.
Review your insurance statements regularly
Stay vigilant about any potential fraud or misuse of your insurance. Check your insurance statements, also known as Explanation of Benefits (EOB), to ensure that the dates, locations, and services billed match what you received. Report any discrepancies to your insurance provider immediately.
Be aware of common insurance fraud schemes
Educate yourself about the various types of insurance fraud, such as double billing, phantom billing, unbundling, and upcoding. Be cautious of individuals recommending specific doctors or attorneys, as they may be compensated for referrals. Get a second opinion if you suspect unnecessary treatment, and maintain records of your office visits, treatments, and transportation receipts.
Know your rights under HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) gives you rights to protect your health information. You have the right to decide if you want to give permission for your health information to be used or shared for certain purposes, such as marketing. You can also request restrictions on how your information is used or disclosed and obtain a report on when and why it was shared. Familiarize yourself with these rights and don't hesitate to ask your provider or insurer questions about them.
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Reporting process: each report is important, but not every submission results in an investigation
The Office of Inspector General (OIG) at the U.S. Department of Health and Human Services investigates reports of fraud, waste, abuse, and mismanagement in the department's programs. While every report is important and reviewed, the high volume of complaints received means not all submissions result in an investigation. The OIG recommends that you review the types of complaints they do and do not investigate, as well as the complaint process, before submitting.
You can also report health care fraud to the FBI's Internet Crime Complaint Center (IC3). Types of health care fraud recognized by the FBI include double billing, phantom billing, unbundling, upcoding, bogus marketing, identity theft, impersonating a health care professional, diversion, and doctor shopping.
Blue Cross Blue Shield (BCBS) companies also work closely with state and federal agencies, as well as advocacy organizations, to report, investigate, and reduce the incidence of insurance and health care fraud. They encourage individuals to take steps to avoid becoming victims of health care fraud, such as reviewing statements after care and reporting any discrepancies to their health insurance plan or payer.
Additionally, the National Insurance Crime Bureau (NICB) provides resources on medical fraud, including common schemes and tips to avoid becoming a victim. They advise individuals to be cautious of individuals who recommend specific doctors or attorneys, as these "runners" often receive compensation for referrals. They also recommend getting a second opinion if you believe you have been prescribed unnecessary treatment and maintaining records of office visits and treatments.
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Examples of insurance fraud: double billing, unbundling, upcoding, and bogus marketing
Insurance fraud can be reported anonymously to the National Insurance Crime Bureau. The False Claims Act (FCA) also enables employees and others aware of insurance fraud to report it safely through a "qui tam" lawsuit, which triggers a government investigation.
Now, here are some examples of insurance fraud:
Double Billing
Double billing is when a medical provider bills an insurer for a service that was not provided. An example is when a physician orders an MRI for financial gain rather than medical necessity.
Unbundling
Unbundling is a common type of healthcare fraud that involves the manipulation of billing practices to increase reimbursement from healthcare programs. Medicare and Medicaid often have lower reimbursement rates for groups of procedures performed together. Unbundling illegally increases profits by billing these bundled procedures separately, resulting in higher reimbursement.
Upcoding
Upcoding is when a healthcare provider submits codes to Medicare or Medicaid or private insurers for more severe diagnoses or procedures than what was actually diagnosed or performed. An example is when a patient visits a doctor for a cough and fever, but the physician assigns a diagnosis of pneumonia without testing for it.
Bogus Marketing
Bogus marketing involves the fraudulent marketing of alternative health insurance coverage options that fail to provide the comprehensive coverage guaranteed in plans compliant with the Affordable Care Act (ACA). These products often leave consumers burdened with high medical bills or inadequate coverage. States have been warning consumers about these fraudulent practices and working to protect them against inadequate coverage and fraud.
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Frequently asked questions
You can report a doctor for insurance fraud to your local Blue Cross Blue Shield (BCBS) company by calling the number on the back of your member identification card. You can also report it to the FBI's Internet Crime Complaint Center (IC3) at ic3.gov. Additionally, the OIG Hotline Operations accepts complaints about fraud in Medicare, Medicaid, and other HHS programs.
Some common types of insurance fraud committed by doctors include double billing, phantom billing, unbundling, upcoding, and identity theft. Double billing involves submitting multiple claims for the same service, while phantom billing is billing for a service or supplies that were never provided. Unbundling is submitting multiple bills for a single service that should have been billed together, and upcoding is billing for a more expensive service than what was actually received. Identity theft involves using another person's health insurance information or allowing someone else to use yours.
Some red flags that a doctor may be committing insurance fraud include recommending specific attorneys or receiving compensation for referrals. Be cautious if a doctor tries to talk you into an injury or prescribes unnecessary treatment. It's always a good idea to get a second opinion and maintain records of your office visits and treatments.
To protect yourself from becoming a victim of insurance fraud, treat your health insurance information with caution. Don't give it to marketers or solicitors, and never sign a blank insurance form. Regularly review your statements after receiving medical care and verify the accuracy of the services billed. If you notice any discrepancies, report them to your health insurance provider.
Insurance fraud is a serious offence and is considered a federal crime under most criminal codes. The FBI and other law enforcement agencies actively investigate and prosecute cases of insurance fraud. Doctors convicted of insurance fraud may face criminal charges, imprisonment, fines, and damage to their professional reputation and license.
