Buyer Beware: Identifying Health Insurance Fraud


 Buyer Beware: Identifying Health Insurance Fraud

If you've been reading the headlines lately, then you know that health insurance fraud is a big problem. Scam artists and fraudsters are taking advantage of unsuspecting consumers to make money by enrolling people in plans they don't need or have to pay for. These schemes can cost people tens of thousands of dollars in higher premiums, higher deductibles, and even out-of-network costs. It's not just individual patients who are getting taken; it's also businesses who sponsor the plans for employees on their payrolls that offer coverage under the ACA or Affordable Care Act [1]. Fortunately, there are some warning signs that you can explore with your doctor or insurance broker to help identify potential health care fraud before it becomes a problem.

Know Where Your Plan Stands

The first sign of trouble is when you can't get clear information about your coverage. If you're not getting the right answers to your questions about what's covered and what's not, you probably have a problem already. If your doctor asks for a payment before she'll provide any services, you should be on your guard. Sometimes scammers will ask for advance payments before they've even established a contract with the provider to deliver a service or product. Your insurance company should cover any services that are medically necessary and not pre-existing conditions, so make sure that any extra charges are completely justified.

If you find out that your plan is a fraudulent one with significant out-of-network charges or pre-existing conditions may be charged more than once, it's probably not the right plan for you. If you have a problem in your health care, figuring out where your coverage stands can help you get access to the right care. If a doctor won't provide the services your plan allows him or her to provide without a huge markup or if you get an unexpected bill for insurance that doesn't match what you thought was covered, then it's time to shop around for alternatives.

Know What You Are and Are Not Covered For

When you buy a plan, it should cover all the services your doctor has indicated are medically necessary. If you can't find your coverage in the coverage list of benefits, then it may be a fraudulent plan and you should end it immediately. Otherwise, you could be paying out-of-network charges or more than what is expected for covered services. A healthcare fraud investigation may help identify if there's an actual problem with your plan or if someone just added themselves into another health policy even though they lack qualifications to do so.

Beware of Appeals to Emotion

Some fraudsters may try to appeal to your emotions when they sell you a policy. For example, they might tell you that you're paying too much for care now and that they can save you money by enrolling you in a plan with an appeals to your compassion. They may offer to help members of under-served or vulnerable populations, like children and senior citizens, which makes it seem more authentic. Make sure that the sales person is actually licensed and authorized by your state and the federal government before you enter any contract with them. This will protect you from scammers who sign up members without their permission or whose licenses are not in order.


Health care fraud can happen to anyone, and it's important to know how to identify it. You can avoid falling prey to health insurance scams by knowing where you stand with your current plan and what you might have done wrong. It's also important not to trust anyone who appeals to your emotions or tries to take advantage of your vulnerabilities when trying to get you to buy a plan they're offering. Use the suggestions here as a guide for how you can avoid fraud in health care going forward. Now that we've covered the Buyer Beware: Identifying Health Insurance Fraud, let's talk about what is actually in the new healthcare law, the Patient Protection and Affordable Care Act (PPACA).

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