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Is there such a thing as health insurance fraud?

retiree with family health insuranceHealth insurance fraud is one of the major problems facing the health care industry in the twenty first century. Many suggest that health insurance fraud is rampant especially within the government based Medicare and Medicaid programs.

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Fraud is more common in larger and more populous states such as California, New York, Texas, and especially Florida, states with large populations of older adults and those who qualify for and receive Medicaid benefits.

How much money are we talking about?

The National Health Care Anti-Fraud Association (NHCAA) estimates that 68 billion dollars is lost each year due to health insurance fraud. While this represents only three percent of the total US health care expenditures, it is still a staggering figure.

Law enforcement experts and others maintain that these estimates are low and that the real costs of health insurance fraud across our nation could be much higher, representing hundreds of billions of dollars in losses, waste, and abuse of our already overtaxed health care system.

What’s being done to curb health insurance fraud?

Newly established citizens’ groups, such as Consumer Watchdog, and government oversight agencies are barely making a dent in curbing this unlawful and costly practice. Many states are enacting laws and establishing offices whose charge is to specifically chase down and prosecute health insurance cheats.

One example is New York State’s Office of the Medicaid Inspector General, OMIG. The OMIG estimates that over the last five years, more than $90 million dollars has been lost due primarily to fraudulent insurance billing and reimbursements. The OMIG has already achieved some positive results through its investigations, but it is only a beginning.

Has insurance fraud been in the news?

In many locales, cases of insurance fraud are just hitting the front pages of local newspapers and now being featured on television and radio news shows. People are just beginning to realize the extent of the problem both locally and nationally.

In Florida, prescription drug fraud is big business. In 2009, the CBS network news show “60 Minutes” aired an investigative story that focused on Medicare fraud in south Florida exposing this huge problem for the first time to a national TV audience.

In 2010, “60 minutes” aired the segment “Medicare Fraud: A $60 Billion Crime,” citing evidence that insurance fraud in south Florida is a bigger industry than illegal drug trafficking, and far more costly.

In just two Florida counties in 2010, insurance fraud cases representing between $300 and $400 million dollars, were brought to trial. This is just the tip of the iceberg.

Does insurance fraud happen just in the larger states and big cities?

No! The abusive practices of insurance fraud are widespread and evident in every facet of the medical services industry throughout the United States. From individual practitioners to hospitals, clinics, and transportation providers, no one is exempt from these unlawful practices or immune from their harmful effects.

What does health insurance fraud have to do with me?

Experts cite health insurance fraud as one of the major contributing factors to our nation’s rapidly escalating medical care and treatment costs. Those who steal and cheat the system, think they are committing “victimless” crimes. However, they end up hurting other consumers, who will have to pay more for their insurance and other necessary health services.

What can we do about medical insurance fraud?

Report it! Everyone can help fight insurance fraud. There are three main ways that citizens can take an active role in watching for and reporting health insurance fraud.

The first is through local law enforcement agencies. Insurance fraud is a criminal offense and may be reported to local police or other law enforcement officials such as the sheriff or district attorney.

Second, insurance companies themselves often have pages on their websites devoted to stopping fraud. Consumers may anonymously leave information on the website without further involvement or the fear of reprisal.

Lastly, many local, national, and regional groups have been established online to give every citizen the opportunity to get involved. One such group is the Coalition Against Insurance Fraud.

Groups like these do good works in the public domain. They often raise operating funds by soliciting donations along with membership fees, which they use to continue the battle against insurance fraud.

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