All You Need to Know about Health-care Fraud and Why We Need to Put a Stop to It

By | June 2, 2016

A lot of people have heard about health-care fraud, but don’t think of it as damaging enough to worry about it. However, health-care fraud is widespread and proving to be very costly to the health-care system. For example, financial losses from healthcare fraud are amount to tens of billions of dollars annually.

Health-care fraud not only costs the government, it can affect your life and that of your loved ones. While the federal government is working to hunt down scammers and reduce instances of fraud, unless each and every person realizes the amount of damage being done, putting an end to fraud won’t be easy.

If you’re ready to learn more about this destructive evil, here is some information for you.

What Is Health-care Fraud?

Health-care fraud is a crime and it involves misrepresenting medical data to gain unauthorized benefit. Read on to know a few risks that health-care fraud exposes you and your loved ones to.

Identity Theft

Medical identity theft occurs when an individual pretends to be someone else by misusing their name, social security number, or insurance card to obtain medical services. This type of fraud can lead to incorrect medical data being stored under the victim’s name.

False Diagnosis and Treatment

Like any other fraud, health-care fraud involves representing false information as the truth. Perpetrators can exploit patients by accessing their medical records and entering diagnoses of medical conditions they do not have, or by noting severe conditions than the patients actually have. By doing so, perpetrators get to submit bogus insurance claims for payment.

Unless this discovery is made, patients believe they are battling a serious life condition and the false diagnosis becomes a part of their documented medical history.

Unfair Billing

Apart from charging unsuspecting patients for services and treatment they never received, or charging them for more expensive procedures, perpetrators may also perform unnecessary medical services to generate insurance payments. It is common for fraudsters to misrepresent non-covered treatments as necessary procedures too; for example, a cosmetic surgery can be billed as a medical procedure to obtain insurance payment.

Another way to charge individuals unfairly is to unbundle services and represent each step of a procedure as a separate one. Accepting kickbacks, waiving co-pays and deductibles, and over-billing benefit plans or insurance carriers are other ways of committing fraud.

Is Fraud Always Provider-Related?

Both health-care providers and beneficiaries can be guilty of committing fraud. Here are some examples of consumer-related health-care fraud:

Altering medical bills and receipts

Filing claims for services not received

Submitting claims for family members who are ineligible

Using another person’s medical benefits

Obtaining multiple prescriptions by moving between doctors

Failing to report other health insurance

Heading to emergency rooms for controlled drugs

How Is Health-care Fraud Destructive?

Health-care fraud not only empties the pockets of insurance providers, but affects stakeholders as well. Consequently, it invites higher premiums and co-pays, restricted benefits, possible denial for future coverage, and lower quality of care. Fraud in government programs like Medicare and TRICARE can also cause taxes to soar.

Most importantly, getting unnecessary medical treatments or receiving less prescription than required can be life-threatening for patients.

What Can You Do to Stop Fraud?

According to Dallas healthcare defense team attorneys, the healthcare sector is the most regulated and sanctioned industry in the United States. That being said, healthcare fraud is seen as a low-risk crime by perpetrators due to the abundance of easy targets in the industry. To help put a stop to this crime, here are some tips to keep in mind:

Ensure your health insurance card doesn’t fall into the wrong hands by keeping it safe at all times.

Do not disclose your insurance information and policy numbers to telephone solicitors or door-to-door salesmen.

If you lose your insurance card, get in touch with your insurance provider immediately and report it to them.

Be an informed customer; keep track of medical services you receive and crosscheck all bills you pay. If things aren’t clear, ask questions.

Go through your policy and benefits statements, and all paperwork you receive from your health-care insurance provider. Do check if the dates of services received are documented correctly.

When filling out claim forms, go one at a time.

Don’t be conned by promotions or advertisements offering free tests or services.

If you suspect that you’re a victim of health-care fraud, report it to your insurance provider immediately.


While the exact cost of health-care fraud is difficult to assess, it’s clear that this crime poses a problem for everyone. Now that you know the implications of health-care fraud, be sure to do the right things to avoid becoming a victim.


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