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What is health insurance fraud?

On Behalf of | Dec 14, 2023 | White Collar Crimes |

Medical insurance fraud is a billion-dollar industry in the U.S. Medicare and Medicaid fraud alone is estimated to cost taxpayers around $100 billion a year, so it’s often aggressively prosecuted.

What, exactly, is health insurance fraud? The answers may surprise you.

9 examples of health insurance fraud

Prosecutors sometimes refer to insurance fraud as “hard” or “soft” in nature. “Hard fraud” involves totally fabricating a claim, while “soft” fraud is more like stretching the truth a bit. In either case, the objective is usually for personal gain. Both kinds of fraud, when intentional, can be a criminal act. Examples include:

  1. Using someone else’s medical card to receive services or fill prescriptions
  2. Lending your medical insurance card to someone for them to use
  3. Lying about your relationship to someone to add them to your insurance
  4. Billing a patient’s insurance for services that were never performed
  5. Using false or irrelevant diagnostic codes with a patient to justify procedures that are not medically necessary
  6. Upcoding, or billing a patient’s insurance for a service that’s more expensive than the one they actually received
  7. Accepting “kickbacks” of some kind (not necessarily cash) for patient referrals to a specific medical center, specialist, testing center or office
  8. Unbundling, or billing each step in a procedure separately instead of as a complete procedure, when doing so serves to increase the amount the insurance will reimburse
  9. Billing a patient more than the allowable co-pay for services that are covered under their insurance

It’s very easy to get caught up in a health insurance fraud investigation. You could be the innocent victim of a relative or friend who “borrowed” your health insurance card out of your wallet. Or, you could be a low-level employee in a medical billing department who had no idea what was actually going on.

If you’re facing an investigation or charges related to some kind of medical fraud, seeking immediate legal guidance is the best way to protect your future.

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