Fraud is a massive, multi-faceted, and rapidly expanding problem. It’s so enormous that when we set out to write a blog post about fraud, we quickly realized there’s no way one article could adequately cover everything you need to know. So, over the next few weeks, we’re releasing a series of blog posts breaking down the most common types of fraud and tips you can follow to mitigate your risk.

You’ve probably heard of medical fraud. But what you might not know is that, even if you’re not a victim, it’s impacting your healthcare expenses. This growing issue costs insurers as much as $234 billion each year, according to the National Conference of State Legislatures, which inevitably trickles down to patients and taxpayers. And it can get very expensive.

Here’s what you need to know to reduce your risk of becoming a victim of medical fraud and help fight this burgeoning problem:

 

What is Medical Fraud?


Medical fraud, also called healthcare fraud, is a crime in which patients or medical providers deliberately deceive the system to turn a profit, receive treatment without paying, or obtain large amounts of controlled substances to consume or sell. 

 

There are several types of medical fraud:

 

  • Medical provider fraud


    This happens when a medical provider, such as a doctor’s office, submits multiple claims for the same service, bills for a service or supplies a patient never received, bills multiple times for the same service, or bills for a more expensive service than the one received. Insurance companies and patients then cover the costs while the providers pocket the overage.

  • Patient or individual fraud


    This happens when someone convinces individuals to provide their personal data and insurance information, such as their identification number, to enroll them in a bogus plan or steal their identity. In some cases, someone may use stolen insurance information to obtain medical treatment and stick the insured individual with the bill. Additionally, theft rings set up fake practices to bill insurance companies or access medical equipment to sell on the black market.

  • Prescription fraud


    This happens when someone creates or uses forged prescriptions to obtain controlled substances, uses someone else’s identity to get their prescriptions, or visits multiple providers to get a prescription filled. Fraud involving prescriptions has snowballed throughout the opioid epidemic, with many people selling ill-gotten prescription medications on the black market

 

How to Fight Medical Fraud


Medical fraud is becoming so expensive that an estimated ten cents of every dollar spent on healthcare in the US goes toward paying for fraudulent claims, according to Cornell Law School. Luckily, there are a few things you can do to fight back and protect yourself:

 

  • Protect your medical personal identifiable information (PII)
    Keep all of your health insurance records, medical records, medical bills, and any other documents containing your medical information in a safe place. Shred all documents and mark out any identifying information on prescription bottle labels before disposing of them. Check your mail often to avoid leaving statements and bills unattended. If you receive statements online, make sure you’re regularly changing the password to your patient portal.
  • Request your national electronic health record (EHR)
    Just as with your credit report, it’s a good idea to periodically review your medical records to ensure you haven’t become a victim of medical fraud. Request paper records every six months and compare.
  • Don’t give medical information to unknown entities
    Do not give any information to anyone who calls, texts, or emails you out of the blue. Always contact your provider directly or check your online account to verify whether a bill is legitimate before paying it.
  • Request amendments to your medical records (if necessary)
    Unfortunately, HIPAA doesn’t provide much control over what’s done with your medical records, but you do have the right to request an amendment. However, if you believe an inaccuracy is a result of fraud, you should contact the FTC to get it corrected or removed.
  • Monitor your personal information
    Leverage actionable threat intelligence to find out if and where your digital identity has been leaked, get notifications about new hacks in real-time, and take steps to boost your security. This can help you stop healthcare fraud before it happens.

 

You may already be a victim of fraud if you’ve gotten calls from debt collectors about bills for services you never received, your insurance provider has informed you that you’ve reached your benefits limit even though you know you haven’t, or you’re denied insurance due to a pre-existing condition you don’t have. But even if you don’t encounter these warning signs, there’s still a chance you’ve been victimized. If you find evidence of potential fraud, it’s crucial you file a police report, alert your insurance company, freeze your credit, and file a medical identity theft complaint with the FTC as soon as possible.

Medical fraud, like many types of identity theft, are on the rise. Many criminals are taking advantage of the pandemic’s drain on the healthcare system and hoping healthcare organizations and individuals are too distracted to notice. But with a bit of knowledge and a lot of vigilance, you can fight back.