Fraud Detection
Health care fraud increasingly contributes to the cost of health care benefits. To combat fraud, this plan is monitored for fraud. We investigate potential fraud by individuals on their claims to obtain benefits, and potential fraud by providers who falsify patient claims in order to increase their own income.
Every year countless dollars are wasted on healthcare fraud. Healthcare fraud is intentionally making or causing to be made any false statement or misrepresentation on a clam, billing, receipt or any other associated materials with the intent of causing unwarranted payment. Healthcare fraud is continually putting people at risk of serious harm and result in huge increases in health insurance costs. The only way to stop it is for individual patients to take back control of their healthcare. Below is a list of some of the more common incidences where healthcare fraud is evident. Be on the lookout for billing inaccuracies such as:
- Billing for services, procedures and/or supplies that were not provided to you.
- Charges submitted by any doctor with incorrect dates for visits or procedures.
- Charges submitted by doctors who did not see you, or whose name you do not recognize.
- Having been unable to receive a reasonable explanation for being kept in a hospital.
- Being told that you must continue to receive physical therapy, rehabilitation therapy, or chiropractic treatments when you believe that you no longer require or are benefiting from such treatments.
- Being told to repeat a test in the doctor’s own office.
- Excessive amount of testing being performed in the provider’s own office as opposed to specimens being sent to an independent outside clinical laboratory.
- Repeatedly being referred to multiple doctors within the same office for unclear indications.
- Excessive follow-up visits or extremely brief or unnecessary visits.
- Billing for the same services more than once.
The only way to stop this healthcare crisis is for each individual patient to use good judgment and common sense to suspect, detect and immediately report to their insurance company any suspected acts of dishonesty and abuse. People should also protect their hard-earned dollars by always reviewing the “Explanations of Benefits” statements received from their insurance companies for truth and accuracy of the claims submitted.
Right of Recovery
A third party may be liable or legally responsible for expenses incurred by a insured for an injury or a sickness. If this plan has paid benefits, then the amount of benefits paid may be recovered up to the amount of the third party's liability for those expenses.
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