What Can We Do To Combat Health Insurance Fraud?

We Are All Aware That Health Insurance Fraud Takes Place

The overwhelming majority of health care providers, including physicians, nurses, physical therapists and pharmacists are caring, honest professionals. Unfortunately a very small number of providers and health care organizations have chosen to cheat insurers, their patients and clients by committing health insurance fraud. This fraud steals hundreds of millions of dollars every year that could have been spent to help people. All of us pay for this with higher insurance premiums and taxes. The following activities are the warning signs of possible health insurance fraud, some precautions to take and the steps to follow if you suspect fraud is taking place.

What is Health Insurance Fraud?

Health insurance fraud under Connecticut law is a criminal act of larceny in the first degree, a sss B felony. Health insurance fraud is defined as the intent to defraud or deceive any health insurer through the use of false, incomplete, deceptive, misleading or omitted information. Your health insurance company and you are cheated by those who:

  • bill for a more expensive service at higher service fee than what was provided,
  • bill for services not provided,
  • bill separately for services that are really included in a single service fee,
  • falsify records and diagnoses to obtain payments, or,
  • participate in illegal kickbacks.

Persons assisting others in such fraudulent acts are also liable under the law. The Federal Government employs similar criminal sanctions and banishment from the program against providers and suppliers committing health insurance fraud against Medicare.

What are the Warning Signs to look for?

Be suspicious if the health care provider or organization:

  • tells you a test or service is free, but needs your health insurance information only for the records,
  • bills the insurance company or Medicare for services you do not recall receiving,
  • tells you they can get payment approved by billing for a service different from those you actually had,
  • uses telephone calls or door to-door selling as a way to sell services or obtain your business,
  • tells you that the more tests they provide, the cheaper they are,
  • offers to provide “free” medical equipment or to waive your Medicare co-payment without first asking about your ability to pay, or,
  • bills for equipment or services for beneficiaries in a nursing home.

While any of these warning signs may actually have an innocent explanation, we need to be watchful of these or any unusual practices. The best way to fight fraud is to make it difficult for the bad apples to operate by questioning any charges that don’t make sense and understanding what your insurer is really being billed for.

What Precautions Can We Follow?

We can follow some specific precautions.

  • Never give out your policy number, insurance identification number or Medicare Health Insurance Claim number, except to your doctor or a provider known to you.
  • Allow only health care professionals to review your health records.
  • Never provide health insurance information over the telephone, ask that any inquires be submitted to you in writing.
  • Never deal directly with suppliers of medical equipment, such as wheelchairs, before consulting with your doctor or your hospital’s discharge planner

What to do if You Suspect Fraud?

Questioning costs and understanding what is billed for your health care is the best weapon against fraud.If you believe a provider or an organization is cheating your health insurance company, call or write to the company that paid the claim.Most insurers and Medicare provide 1-800 telephone fraud hotlines. If you are unsure of who to contact, call the main number of the company and ask for the special investigations unit or a health claim representative. Before contacting the company, review the facts that you know and gather the bills, benefit explanations, and any notes you have about your treatment. Write down:

  1. the provider’s or health care company’s name and any identifying numbers,
  2. the date(s) of and service(s) you are questioning,
  3. your insurance identification and claim numbers or your Medicare number,
  4. the amount billed for the service, and,
  5. the reason you believe that the claim should not be paid.

Health insurers and the Medicare program have established special investigative units to review and follow-up on your information or complaints. The Connecticut Insurance Commissioner has established an anti-fraud Unit to assist the public and the insurers in combating insurance fraud. Staff from this Unit can assist you to find the right place to report your information and to resolve your concerns about any suspected fraudulent activities. You may contact this Unit at (860) 297-3933, or, you may write directly to the Unit at the

Connecticut Insurance Department
Anti-Fraud/Arson Unit
PO Box 816
Hartford, CT 06142-8016.