Part II If it Sounds to Good to be True: Health Insurance Scams

As a follow-up to yesterday’s post If it Sounds to Good to be True: Scams, Frauds and Quacks, today’s post focuses on health insurance. With the new health reform law going into effect, be aware of even more scams. According to the National Health Care Anti-Fraud Association

DON’T
• Don’t buy insurance online or over the phone, based on mailers, fliers or ads without investigating first and clearly understanding what you are buying.
• Don’t respond to high pressure or fear tactics from aggressive salespeople.
• Don’t provide your Social Security number, bank account numbers or credit card numbers before confirming that you are dealing with a legitimate company, and don’t give out personal information over the phone.

DO
• Do take the time to research any company before purchasing a health insurance policy from it—a few minutes invested in searching the Internet is worth your time.
• Do check with your state’s Insurance Department to make sure the company is licensed to do business.
• Do compare insurance coverage.
• Do document your dealings with any company from which you are considering purchasing insurance.
• Do get a list of doctors and other providers that participate with the insurance plan you are considering.
• Do ask LOTS of questions.
• Do report suspected fraud to your state insurance department.

If you suspect or know you have been victim to any of the following by a health provider contact the National Health Care Anti-Fraud Association

• Billing for services that were never rendered—either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.

• Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding"—i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying "inflation" of the patient's diagnosis code to a more serious condition consistent with the false procedure code).

• Performing medically unnecessary services solely for the purpose of generating insurance payments—seen very often in nerve-conduction and other diagnostic-testing schemes.

• Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments—widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as "nose jobs” are billed to patients' insurers as deviated-septum repairs.

• Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary.

• Unbundling - billing each step of a procedure as if it were a separate procedure.

• Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.

• Accepting kickbacks for patient referrals.

• Waiving patient co-pays or deductibles and over-billing the insurance carrier or benefit plan.