Health insurance fraud costs the industry between $30-100 billion per year, raising premiums for all policyholders. It is defined as intentionally deceiving an insurance company to receive benefits, such as claiming expenses not incurred or hiding pre-existing conditions. Providers also commit fraud by overbilling or billing for services not rendered. Recently, fake insurance companies have also targeted consumers by offering low rates but disappearing without paying serious medical claims. To avoid fines or prison, policyholders and providers should be honest in all dealings with insurers.

1. Stay Legal! Avoiding Insurance Fraud
Everyone knows that the health insurance industry is continually rai
sing monthly premiums, and many feel this is unjust to you as the co
nsumer. However, the health insurance industry has had to fight incr
easing health insurance fraud. The amount of money spent on investig
ating and prosecuting fraud is then passed on to policyholders. Many
people do not understand what health insurance fraud entails, thoug
h. With reports estimating health insurance fraud is a $30 billion t
o over $100 billion industry per year, the topic should not be taken
lightly. Every health insurance policyholder should understand what
health insurance fraud is and its consequences. By doing so, you ar
e more able to recognize and fight fraud.
Health insurance fraud is typically defined as intentionally deceivi
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ng, misrepresenting, or concealing information to receive benefits f
rom the insurance company. Essentially this means that you assert th
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at you paid for certain medical procedures or expenses out-of-pocket
which you have not actually received, and you are submitting claims
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to the insurance company to receive reimbursement. Another example
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of member fraud is to conceal pre-existing conditions or to alter me
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dical documents so that non-policyholders or ineligible members rece
ive medical benefits under your policy. Perhaps your sister does not
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have insurance and needs medical attention. Having her use your nam
e and policy to cover the expenses is health insurance fraud. While
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you may think that this is a small issue in comparison to your siste
r receiving treatment, it is actually very serious to your health in
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surance company and industry, and will result in fines and possible
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imprisonment if your are caught.
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Not only policyholders commit fraud, but providers (physicians, hosp
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itals, etc.) do as well. Since physicians and hospitals bill the ins
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urance company for services they provide for you, they are also rece
iving reimbursement from the insurance company. When providers commi
t fraud, they may be billing the insurance company at higher rates f
or services rendered or they may bill for services you never receive
d. In these cases, you will probably be asked to cooperate in the in
surance company's investigation.
Another type of health insurance fraud that has developed recently
targets the policyholder more than the insurance company. Schemes h
ave developed where fake insurance companies or agents sign unsuspe
cting customers for coverage at surprisingly low premium rates. The
y often act much like a regular insurance company for the first few
months, paying for smaller medical claims like physicians visits.
But once you have a more serious medical condition that needs treat
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2. ment, the insurance company will disappear - along with the money y
ou have been paying in premiums.
The rule with health insurance fraud is much like that of any other
scam: if a deal seems too good to be true, just remember - it probab
ly is. Remember to be honest in your dealings with health insurance
companies and expect the same in the return from these companies, as
well as your health care providers. Stay legal to avoid fines and p
rison and to continue receiving health insurance coverage.
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