Unveiling The Dark Side: Understanding Medical Insurance Fraud

Medical insurance fraud is a crime that occurs when a healthcare provider or individual deceives an insurer in order to receive greater reimbursement or pay unauthorized benefits to the policyholder. This can be done by billing for services, procedures and/or supplies that were never rendered, charging for more expensive services than those actually provided, performing unnecessary services for the purpose of financial gain, misrepresenting non-covered treatments as a medical necessity, or allowing someone else to use their identity and insurance information to obtain health care services.

Health insurance fraud occurs when a company or individual defrauds an insurer

Health care fraud can be committed by medical providers, patients, and others who intentionally deceive the health care system to receive illegal benefits or payments. Health insurance fraud occurs when a health care provider or individual deceives an insurer in order to receive greater reimbursement. False or misleading information is provided to a health insurance company in an attempt to have them pay unauthorized benefits to the policyholder, another party, or the entity providing services. The offence can be committed by the insured individual or the provider of health services.

An individual subscriber can commit health insurance fraud by: allowing someone else to use his or her identity and insurance information to obtain health care services; using benefits to pay for prescriptions that were not prescribed by his or her doctor. Health care providers can commit fraudulent acts by: billing for services, procedures and/or supplies that were never rendered; charging for more expensive services than those actually provided; performing unnecessary services for the purpose of financial gain; misrepresenting non–covered treatments as a medical necessity.

Medicare and Medicaid fraud is medical billing fraud specific to these government benefit programs. It is when a health care provider claims Medicare or Medicaid health care reimbursements that they are not entitled to in order to dishonestly collect money. Home health care fraud is when home health agencies bill insurers, government benefit programs, or homebound patients for unnecessary services or for services that were never delivered.

False information is provided to a health insurance company to pay unauthorized benefits

Health insurance fraud occurs when a company or individual defrauds an insurer or government health care program, such as Medicare (United States) or equivalent State programs. False or misleading information is provided to a health insurance company in an attempt to have them pay unauthorized benefits to the policyholder, another party, or the entity providing services.

The offense can be committed by the insured individual or the provider of health services. An individual subscriber can commit health insurance fraud by:

• Allowing someone else to use his or her identity and insurance information to obtain health care services
• Using benefits to pay for prescriptions that were not prescribed by his or her doctor

Health care providers can commit fraudulent acts by:

• Billing for services, procedures and/or supplies that were never rendered
• Charging for more expensive services than those actually provided
• Performing unnecessary services for the purpose of financial gain
• Misrepresenting non–covered treatments as a medical necessity

Health care fraud can be committed by medical providers, patients, and others who intentionally deceive the health care system to receive illegal benefits or payments. It affects everyone—individuals and businesses alike—and causes tens of billions of dollars in losses each year. It can raise health insurance premiums, expose you to unnecessary medical procedures, and increase taxes. The FBI is the primary agency for investigating health care fraud for both federal and private insurance programs.

Medicare and Medicaid fraud is specific to government benefit programs

Medicare and Medicaid fraud is medical billing fraud specific to government benefit programs. It is when a health care provider claims Medicare or Medicaid health care reimbursements that they are not entitled to in order to dishonestly collect money.

Medicare and Medicaid fraud is a type of health insurance fraud. Health insurance fraud occurs when a company or an individual defrauds an insurer or government health care program, such as Medicare (United States) or equivalent State programs. The manner in which this is done varies, and persons engaging in fraud are always seeking new ways to circumvent the law.

Damages from fraud can be recovered by use of the False Claims Act, most commonly under the qui tam provisions which reward an individual for being a "whistleblower", or relator (law). The FBI estimates that Health Care Fraud costs American tax payers $80 billion a year.

The Attorney General’s Medicaid Fraud Control Unit investigates allegations of Medicaid fraud. To file a Medicaid complaint, contact the Austin headquarters. Mail: Medicaid Fraud Control Unit at the Office of the Attorney General, P.O. Box 12307, Austin, TX 78711-2307.

Home health care fraud is when home health agencies bill insurers, government benefit programs, or homebound patients for unnecessary services or for services that were never delivered.

Home health care fraud is when home health agencies bill insurers for unnecessary services

Home health care fraud is a type of health insurance fraud that occurs when home health agencies bill insurers, government benefit programs, or homebound patients for unnecessary services or for services that were never delivered. This type of fraud is committed by health care providers who deceive the health care system to receive illegal benefits or payments.

Home health care fraud can be committed in several ways. For example, a home health agency might bill for services, procedures, and/or supplies that were never rendered, or charge for more expensive services than those actually provided. In some cases, unnecessary services may be performed for the purpose of financial gain. This type of fraud can be very damaging to the health care system and can raise health insurance premiums, expose patients to unnecessary medical procedures, and increase taxes.

The FBI is the primary agency for investigating health care fraud for both federal and private insurance programs. The FBI investigates these crimes in partnership with insurance groups such as the National Health Care Anti-Fraud Association and the National Insurance Crime Bureau.

To report health care fraud, you can visit the FBI's Internet Crime Complaint Center (IC3) at ic3.gov. You can also contact the Attorney General’s Medicaid Fraud Control Unit to file a Medicaid complaint.

Medical billing fraud is when a health care provider claims reimbursements they are not entitled to

Health insurance and medical billing fraud occurs when a health care provider or individual deceives an insurer in order to receive greater reimbursement. False or misleading information is provided to a health insurance company in an attempt to have them pay unauthorized benefits to the policyholder, another party, or the entity providing services. The offence can be committed by the insured individual or the provider of health services.

Health care fraud can be committed by medical providers, patients, and others who intentionally deceive the health care system to receive illegal benefits or payments. Medicare and Medicaid fraud is medical billing fraud specific to these government benefit programs. It is when a health care provider claims Medicare or Medicaid health care reimbursements that they are not entitled to in order to dishonestly collect money.

Home health care fraud is when home health agencies bill insurers, government benefit programs, or homebound patients for unnecessary services or for services that were never delivered. Damages from fraud can be recovered by use of the False Claims Act, most commonly under the qui tam provisions which rewards an individual for being a "whistleblower", or relator (law). The FBI estimates that Health Care Fraud costs American tax payers $80 billion a year.

Frequently asked questions