Insurance fraud is defined as any act committed with the intent to fraudulently obtain payment from an insurer. A big chunk of the total claims received by insurers are fraudulent claims that run into billions of dollars annually. Health Insurance fraud is today a very serious problem and a great challenge, as it has proved to be very costly to America’s health-care system.

Just last week two New York based doctors were convicted of defrauding 60 insurance companies and a city transit agency of at least $15 million through clinic billing scams and were sentenced to be behind bars. Refer to the news article, http://www.amny.com/news/local/ny-bc-ny–medicalbillingsca0211feb11,0,437123.story?track=rss

It is now evident that our Public healthcare programs such as Medicare and Medicaid are especially conducive to fraudulent activities, as they are often run on a fee-for-service structure.

Dishonest Physicians and healthcare providers are also known to engage in fraudulent activities that include,

  • Up-coding/Upgrading (Billing for more than actual service provided)
  • Providing and subsequently billing for treatments that are not medically necessary
  • Scheduling extra visits for patients
  • Referring patients to another physician unnecessarily
  • Billing for services to accompanying family members
  • Ordering unnecessary tests

With newer and better coding systems and techniques in place and new policies and vigorous plans being made to revive the ailing US health industry, let us hope that the future will bring better reforms with lesser frauds, and provide efficient and effective health insurance for the entire population in this country.

Outsource Strategies International (OSI) is a US based medical transcription company that offers outsourcing solutions in medical billing, medical coding and medical transcription services to clients in the US States and outside.