What Is Considered Medical Insurance Fraud?

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    Health Providers

    • Health care providers may engage in medical insurance fraud by engaging in several unethical practices. A provider may purposely overcharge for procedures in an attempt to collect more from the insurance company than he normally would. Rather than inflate the price of procedures, the provider may simply order unnecessary tests, procedures and equipment for the patient in an attempt to incur more charges to pass to the health insurance company.

    Health Insurers

    • Companies that provide, or claim to provide, health care insurance coverage can also engage in medical insurance fraud. A company may engage in activities to overcharge members of a certain payment group, believing the group will not notice the higher payments. A company may also represent itself as a medical insurance provider, accepting payments from customers, only to not provide any coverage. Other medical insurance providers refuse to cover procedures that were supposedly covered by the policy purchased by customers.

    Patients

    • Patients may knowingly engage in fraudulent activities with health practitioners with the promise of receiving a kickback or a portion of the fraudulently obtained money for helping to obscure the fraud. These patients will help validate any claims made by a health provider when questioned by the health insurance company about services and procedures performed during the patient's visit to the provider's facility.

    Accident Fraud

    • Some individuals engage in medical insurance fraud when they try to make it appear they have fallen victim to a medical condition due to the negligence of an organization or other individual. One such scenario involves a person faking a slip and fall in a store, with the intent of claiming bodily injury and medical expenses only to collect money falsely from the store. Other accident fraud scenarios involve trumping up or overstating the extent of a person's injuries from an automobile accident or incident that occurred at the person's place of employment. Workplace injury claims may be used as an attempt to deceptively collect medical disability payouts as well.

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