Health insurance fraud, which involves intentionally deceiving or falsifying health insurance claims for financial gain, is a major problem that increases healthcare costs and delays medical care. The three most common forms of health insurance fraud are false claim submissions, false personal injury claims, and overtreatment. It is estimated that insurance fraud costs billions of dollars each year in the US alone. Preventing this costly and harmful form of fraud requires collaboration between healthcare providers, consumers, and insurance companies.
Every year, billions of health insurance claims are processed by health care providers and individuals to cover the costs of health care. However, in some cases, criminals try to trick insurance companies for financial gain. The act of intentionally attempting to deceive or falsify health insurance claims in an attempt to earn more money from a health insurance company is considered health insurance fraud.
With health care costs reaching astronomical levels around the world, entities that commit health insurance fraud are a major part of the problem. When a health care provider or insurance company has to spend more time resolving potential fraud, staffing and administration costs rise, and medical costs rise as a result. People who commit insurance fraud end up hurting others as a result of this illegal behavior.
In addition to increasing health care costs, health insurance fraud results in claims taking longer to process. This can delay medical care for the people who need it most. For example, if a patient is waiting for approval from an insurance company for a specific surgical procedure, it may take days or even weeks for the insurance company to obtain approval. This can cost the patient additional suffering or even death while she waits for treatment.
The three most common forms of health insurance fraud are false claim submissions, false personal injury claims, and overtreatment. Insurance fraud may originate with the individual attempting to “fake” an injury in order to receive benefits, or the health care provider may be the responsible party. In any case, health insurance fraud is a punishable offense in most regions.
False or excessive claim filing occurs when a health care provider attempts to bill the insurance company for a service that was not actually performed. The provider may attempt to bill the insurance company for equipment and supplies that were not used, or that may be determined to be excessive given the nature of the service. This increases the claim and may also cost the patient an additional fee.
Personal injury claims backed by “personal injury mills,” which are lawyers who profit by exaggerating the victim’s actual injury, cost the health insurance industry millions each year. In some cases, the victim fakes her injuries to receive benefits. This type of health insurance fraud can take years to correct and overburdens the legal system as well as the health insurance industry.
It is estimated that in the US alone, money lost to insurance fraud accounts for billions of US dollars each year. Health insurance fraud can be prevented through careful and accurate evaluation, recording, and billing of medical treatment by health care providers. It is up to health care providers, consumers, and insurance companies to work together to prevent this costly and harmful form of fraud.
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