In my 30 years practicing emergency medicine it wasn't unusual for a patient to come in seeking treatment by "borrowing" someone else's insurance ID.
One patient I remember well came in complaining of chest pain. It turned out that the ID he was using belonged to another patient who I had treated several years before for a heart rhythm disturbance. Once we compared their EKGs, we realized these were two different people. The fraudulent patient didn't have a heart problem. We discovered his deception before administering any drugs or treatments that would have been inappropriate, or even potentially dangerous to him.
This type of fraud is not only a problem for hospitals and insurers, but the fraudulent patient may receive treatment based on someone else's medical history and the medical records of the patient whose ID is used can become distorted and inaccurate.
The annual price tag of health care fraud adds up to a staggering $226 billion, according to the National Health Care Anti-Fraud Association According to the White House, improper payments in the Medicare and Medicaid programs - including fraud as well as errors and mistakes - cost $54 billion last year. All of this is a huge drain on an already strained medical system.
How can we get a better handle on medical fraud to stop it? How can we reduce abuses and mistakes that illegitimately take money out of our system?
One of the best ways to protect ourselves is to prevent the fraud in the first place. Medicare and Medicaid, however, are required to pay claims within 30 days. This means that fraudulent claims are often not discovered until after they are paid.
Today, government, private insurers, medical professionals and individual patients are getting a whole lot smarter and using new, more sophisticated methods to spot the fraud early and stop payments. The challenge is to identify fraud while minimally inconveniencing legitimate patients and providers.
The Affordable Care Act includes tougher rules and criminal penalties, and expanded recovery efforts.
On July 22, President Obama signed the Improper Payments Elimination and Recovery Act, which extends to all federal agencies, including Medicare, efforts to reduce payment errors and fraudulent payments by requiring agencies to have corrective plans and targets for reducing errors and overpayments. This holds some hope for success. A Medicare pilot program that was carried out in a number of states over a three-year period recouped $992 million.
Insurance companies are also using advanced technologies and analytical software to sort through tens of thousands of providers and hundreds of millions of claims within minutes to search out fraud and abuse. Health benefits companies using these new systems have achieved a nearly 90 percent reduction in fraud, a sharp contrast to previous methods, which typically net 20 to 30 percent reductions. For example, Aetna's special investigations unit was able to identify questionable claims at more than 200 facilities, and saved more than $20 million.
On an individual level, here are a few simple things you can do to protect yourself:
- Don't give personal or medical information on the phone unless you initiated the contact and you know who you're dealing with.