Why You Should Care About Health Care Fraud

How do doctors get paid? Healthcare isn’t free in any country: citizens pay for it. 

“We pay doctors when they provide lots of health care, not when they provide good healthcare.”

About 19% of the USA’s GPD goes to healthcare. 3.5 Trillion. Why does the US spend so much on health care? Why do Americans pay at least twice as much as any other developed country?

To put things worse, healthcare scams cost us $70 billion per year, which adds up quickly. Patients (not only in America) are overpaying for underperformance.

Given the government expenditure, fraudsters want a piece of the cake. Ironically, many of healthcare fraud cases aren’t too hard to prevent with a bit of self-awareness.

There are many types of fraudulent cases and they are committed by a wide variety of people. When we talk about healthcare fraud we are talking about actions such as:

  • Billing for services that have not been provided
  • Billing for a service that is covered by insurance when it was not the procedure provided
  • Billing for unnecessary treatments
  • Billing for services that have a higher reimbursement rate
  • Billing for separate services that could be bundled together
  • Billing for services that were not provided to the named individual
  • Intentionally receiving numerous prescriptions from different doctors
  • Adding people to your healthcare plan that do not qualify

This is by no means an exhaustive list. There are new schemes taking place all the time, and many of them slip through the cracks. As a consumer, you need to think about what you can do to fight back against healthcare fraud.

Healthcare: Good investment or Money Pit?

Scammers have good reasons to get into the system. Once you have your “business” running, you can make a fortune with a low risk of getting caught. Even if it means misrepresenting stats, or hiding information, or endangering the patient’s life.

Healthcare fraudsters will:

  • Charge you for services you didn’t use or need
  • Misrepresent existing reports to pay more
  • Offer “free tests” to access your medical data

Scammers have no interest in solving your health problem. They prefer to solve the effects— not the causes— so you keep coming back to pay for something that won’t help you.

Awareness: nobody cares as long as the patient doesn’t find out the truth.

Who would do something like that?

Healthcare scammers have multiple profiles, each one with different motivations. It could be:

  • a. A generic scammer. They use the same techniques to steal money and information. They get into healthcare because of the reward. (see Different Types Of Scams)
  • b. An imposter. A con man poses as your healthcare company to get your data and steal your accounts. They use healthcare as a method to get to ALL your accounts. (see Identity Theft)
  • c. Private Companies. Opportunity comes along with demand. Dishonest firms make more profits by overcharging patients for needless services. It could be pharmaceutical, a health insurer, or a treatment center. (see Cramming)
  • d. Dishonest Patients. Knowing how expensive healthcare is, it’s not surprising that patients may try to fake the system. They can use someone else’s privileges or show the wrong information to qualify for services. (see Disability Fraud)

How Do Healthcare Scammers Reach Out To Me?

If you fell for a scam, it may not be your fault. Healthcare fraud is not something you usually find (although you can prevent it); the scammer finds YOU and catches you off-guard.

Before commiting fraud, perpetrators research their potential victims. They prefer to target:

  • Healthcare Habitual Patients: Big spenders and the elderly.
  • Geographic areas: Where do people spend the most?
  • Miscellaneous variables: Website visits, purchase history, platforms used, even sucker lists.

Regardless of the variation, they use intrusive marketing to contact. Cold email, phone calls, advertising, fake referrals, and reward programs.

Will Medical Fraud Ever Stop?

With over $3 trillion per year investments in healthcare, scam cases will keep happening for a looong time. However, preventive measures can discourage con men from tricking you, hence reducing the risk. 

Are we too easy to scam? Before changing the system, we need to take charge of our situation. Scam cases may stand for a mere 3% today, but these schemes “mutate” as fast as medical security improves. Maybe faster.

Are people aware? How much regulation do we need in this sector? Remember those numbers: almost $70 billion lost every year, excluding the hundreds of unreported cases.

Your Healthcare Anti-Scam Guide: Types, Red Flags, & Tips

As a broad topic, healthcare splits into health insurance, medication, and medical services. Scam can come up as a combination of these three, and it’s complex to detect without previous knowledge.

A. HEALTH INSURANCE

Why insurance first? Because the service prices are based on many abstract conditions. How do you explain this sector? Most people can’t. Use some jargon to hide your scheme, and people will say “Yes” to avoid feeling dumb. A scammer magnet.

Red Flags To Check

  • They have more interest in the deal than trying to help you. You don’t know yet whether you need insurance, and these salesmen are already talking about prices. “Here’s a deep discount for the first six months. Only valid if you sign up today!” You know their intentions when they talk to you like this.
  • No valid licenses / ERISA license. Your health insurer isn’t properly accredited or doesn’t have a license in their state. ERISA is a federal organization, a sure sign the insurer is fraudulent.
  • Price inconsistencies. The insurer who contacted you has a small history in the business. His prices— either higher or lower— differ over 20% of the average offer. If it sounds too good to be true…
  • We don’t sell insurance! If they don’t sell anything, why are they messaging you in the first place? Oh, they call it a “healthcare privileges program.” Perhaps they actually sell nothing and reach out for a survey or similar.
  • Free Test. Why free? And why you? Some companies promote free healthcare services and collect your data along the way. An identity theft.

Key Takeaways

  • Do not listen to insurers who don’t let you speak and rush with limited deals.
  • Verify your health insurer
  • Stick to the average market price. Underpriced deals may add hidden fees, strict conditions, or not exist.
  • Do NOT share your ID information, SSN, or medical reports, even if it’s free. 
  • If you don’t need insurance, ignore them. You don’t need that “offer you can’t refuse.”

B. MEDICATION

Whenever you need it, one pill can make you feel better as you recover from illness. But as easy as it is to stop the effects, it’s a hundred times easier to mess up if you use the wrong formula.

Counterfeit medication, illegal drugs, fake pills. Change the tiniest component, and what once was a healing substance now becomes a life threat. 

Pharmaceuticals can get it wrong once and give you a wrong (or expired) medicine. But 99% of faulty medicine comes from con men reselling products.

Red Flags To Check

  • They sell prescribed products, no prescription needed. Ask for it, even if you don’t need prescribed medicine. Legit pharmaceuticals can’t sell it to you due to the health risks. Bogus dealers will do it, no problem.
  • No history. There’s nowhere to check for reviews, case studies, and medical audits. You can’t find anything to validate, which means you expose yourself to all the uncertainty.
  • All-In-One Magic Pill! They sell you the ultimate drug that does it all. God knows for how much. No matter what you tell these dealers, they have you covered. They’ll say Yes to any question until you say Yes too.
  • Free Samples. A dealer gives you a sample in case you want to buy more. But who would take a pill from a stranger? That’s why they resell well-known brands at lower prices. Usually, these drugs have been manipulated to create addiction and make you buy.
  • Trendy Drugs. When CBD was legalized recently, everyone was talking about it in 2019. When corona appears in 2020, everybody talks about miraculous cures. Strangers somehow get into your inbox and web browser to sell you the latest pill.

Key Takeaways

  • Ask about prescriptions to spot illegal dealers.
  • Never be the first person to try an experimental drug or a brand new firm.
  • All-in-one, no-side-effects pills don’t exist. Suspect of anyone who sells you the panacea.
  • A dealer offering samples knows you’ll come back. Stick to official brands.

C. MEDICAL SERVICES

Americans fear to go to the hospital, and not precisely for health issues. The situation is beyond absurd: you can find stories of people in accidents screaming: “Don’t call the ambulance. I can’t afford it!”

Should treatments be really that expensive? Or are we being fooled by medical fraudsters?

Red Flags To Check

  • Your bill doesn’t match with your medical reports. They can tell you one thing on the consultation and then charge a different amount, hoping you won’t notice.
  • Hard-to-read meaningless jargon. Double-speaking can hide “medical service fees” that only serve to profit from patients. The victim often misunderstands the statement, thinking the payment is normal/necessary (see Cramming).
  • Document mess. The dishonest doctor either loses some of your papers or forges a signature to authorize requests without your permission. You remember signing that paper, but you can’t prove it to anyone.
  • Unnecessary prescriptions. One problem should involve one solution. When doctors prescribe multiple pills, they are trying to cover every isolated case you may experience. Despite the valid excuses, you will rarely need them.
  • The doctor fails to prove the license. They don’t have a valid license, it looks forged, or they can’t refer you to the entity who accredited them. The person is self-verifying, which has no use. No certification means the law doesn’t require them to work on your best interests.

Key Takeaways

  • Verify your treatment center before any operation
  • Double-check any bill they give you. It’s likely not a “computing error.”
  • Ask for a copy of anything you sign. Let clear that you only signed the papers you copied, and it’s your responsibility. Now, they cannot lose or forge documents. If they do, you can report and back up with proof.
  • Look for solutions before visiting the doctor. By the time you consult with the doctor, you should have an idea of what they will tell you and what you need from them. Don’t blindly follow your doctor: prepare and consult him to validate your own conclusions.

Five Common Tactics Scammers Use to Fly Under the Radar

  1. Useless free tests to gather data.
  2. Charging service fees with ambiguous terminology.
  3. Forging/misrepresenting the patient’s documents.
  4. Advance fee scams via insurance premiums and medical treatment.
  5. Kickbacks. Ever wondered why you pay so may for add-on prescriptions? One provider refers patients to someone else’s products and treatments to get commissions or referrals.

Better To Prevent Than Cure

If you are already having health issues, money scams must be the cherry on top of the cake. Scammers have dozens of schemes to rip you off. They’ll likely always be one step ahead of you.

The solution? Prevent from getting into these situations. You don’t need to research and predict every single scheme out there. Just stick to the best practices, and you won’t have to deal with them.

How to Avoid Surprise Bills

When possible, choose in-network care to save costs. Here, the provider charges the insurer, who will review the bill and pay while providing their contract. The patient pays the remaining amount.

Out-of-network exposes you to facility fees and variable treatment rates. If you don’t see it fair, opening a dispute can get you more convenient pricing.

It will save you a lot of hassle to prepay your treatment, which can even include a discount. What matters is that once it’s paid, you know they won’t charge anything more.

How to Avoid Medicine Scams

Verify the provider before ordering medication. Most people assume a product doesn’t change no matter who sells it, which puts them at risk of counterfeits, expired medication, and manipulated drugs.

You’ll likely not find out 100% of the facts until you contact the dealer. Ask about previous cases and social proof.

Although it’s rarer than scams, official pharmaceuticals can make errors too. No matter where you buy the official drug, use the product with caution anyway: 

  • Make a visual inspection to spot inconsistencies.
  • Take a below-average dose and wait for a reaction. If there’s no side effects, it should be safe.

You may not refund a defective product, but at least you won’t compromise your health.

How to Avoid Unfair Insurance Charges

You can ask your insurer for an EOB bill (Explanation Of Benefits). This document shows all your credentials and the amount your insurer covered after a treatment.

Weeks after using a healthcare service, your insurance will have all the details of the EOB. You can check if the numbers make sense.

Don’t hesitate to use saving techniques such as bundling, which can save 5 to 20% of the costs. Consider merging health insurance with other subscriptions (home, auto insurance) into one.

Do you use the service often? Maybe once a year? Choose a health plan that fits you.

How to Avoid Unnecessary Prescriptions

Check up what you need and remove anything else. The more medication you take, the more chance to have side effects.

Before your doctor sends you with the prescription, double-check your health report. Do NOT assume every doctor you meet will know this information.

You’d be surprised how many times it happens because patients fear to question their doctors. How are you going to doubt a professional? The elderly fall for this mistake all the time.

Don’t Let Their Field of Expertise Intimidate You

Let them know every pill you have been taking, when, and how. Next, questions: What options do I have? What happens If I don’t take it? Is this product covered by my health insurance?

If that prescription is a must-have, ask: “Doctor, are you giving me the smallest dose required to make an effect? Exactly when and how to use it?”

Wrapping Up: A Healthcare Service You Deserve

Like any industry, you will find highs and lows. Although honest professionals outnumber fraudsters, that won’t stop unaware patients from falling for healthcare scams. Ask accurate questions that prevent overcharges.

Some doctors misrepresent their consultation sessions to make you overpay. Write down your appointments on a calendar, so you clearly remember if that one-hour session charged was actually twenty minutes.

Beware where you share your personal data. Before using a healthcare service, read a bit about the recent inspections and cases. Follow the best practices to get the best price for the healthcare service you deserve. Nobody will care about your health more than you.

Share it
Subscribe
Notify of
guest
1 Comment
Newest
Oldest Most Voted
Inline Feedbacks
View all comments
1
0
Would love your thoughts, please comment.x
()
x