Why should consumers care about fraud, and what can they do to help prevent it?
People should care because fraud impacts both costs and coverage. High amounts of fraud mean higher premiums and out-of-pocket costs, and can result in reduced benefits or coverage. For employers, fraud can increase the cost of benefits that they provide to employees, resulting in an increased cost of doing business, as well as resulting in higher premiums for the employees.
Other consequences include falsified patient records, which could affect future coverage and may impact treatment the consumer receives later as doctors act on false information in health care records. In addition, patients may suffer through unnecessary testing in order to increase the insurance reimbursement to a medical provider.
Consumers can help prevent fraud by not sharing their insurance information with anyone and protecting their insurance card as they would a credit card. If it is lost, report the loss immediately to the carrier, and don’t give out policy numbers to anyone.
Pay close attention to the health care services you receive and review benefits statements carefully. Read everything thoroughly and make sure that you actually received the services outlined in the statement and that dates are correct. And if you suspect that you are a victim of fraud, report it immediately to the insurance company.
In addition, be suspicious of offers for free medical care, such as solicitations for participation in clinical trials, as these can sometimes be a front for those seeking to commit fraud. Services may be offered for free, but the provider may bill the consumer’s insurance company for thousands of dollars in fraudulent charges. And, never sign a blank claims form.
Finally, ask questions about the services recommended by your provider, why they are needed and what they cost. As an informed consumer of health care, you can help decrease the cost of fraud, protect your medical records and keep your premiums in check.
What are insurance carriers doing to combat fraud?
Most insurance companies have anti-fraud units, with staff dedicated to monitoring and investigating suspected fraud. Companies also work closely with state and federal law enforcement agencies to detect fraud that may be occurring, and coordinate with contractors and providers to monitor suspicious activity.
In addition, they are working with providers, suppliers, physicians and beneficiaries to educate them about the signs and consequences of health care fraud.
MARTY HAUSER is the president of SummaCare, Inc., a provider-owned health plan located in Akron, Ohio. SummaCare offers a full line of health plans and ancillary products. Through its extensive network of more than 7,000 providers and more than 50 hospitals, SummaCare offers coverage to more than 115,000 members throughout northern Ohio. Reach him at [email protected].
