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How Do Health Insurance Companies Detect Fraud?

LawMD

Watch this video to get an answer to “how do health insurance companies detect fraud?”

 

Learn More:

How Can Health Insurance Fraud Claims Be Avoided?

What Are Examples Of Health Insurance Fraud?

Health Insurance Fraud Or Healthcare Fraud

 

Video Transcript

Timestamps
0:00 Intro
0:35 How Do Health Insurance Companies Detect Fraud? How Companies Detect Insurance Fraud
0:59 How Do Health Insurance Companies Detect Fraud? Detecting Fraud
1:25 How Do Health Insurance Companies Detect Fraud? Procedural Requirements To File A Fraud Case
1:54 What Happens After The Affidavit Is Filed?
2:34 After The Investigation

Healthcare fraud is frequently picked up by insurers. They have compliance officers, they have their own integrity units that constantly review the work performed by those physicians and other providers who are on their panels. They’re able to compare more or less what one provider does versus another.

0:35 How Do Health Insurance Companies Detect Fraud? How Companies Detect Insurance Fraud

If you have one particular person who seems to be an outlier. Maybe this person is billing so much more than his peer group or maybe he’s focusing on some single procedure or cluster of procedures where he’s billing these over and over again at very high numbers. Frequently, insurers will pick up on those frauds.

0:59 How Do Health Insurance Companies Detect Fraud? Detecting Fraud

Now, they may even investigate those themselves. In the case of a private insurer, if it’s a Medicare supplemental policy that does the initial investigation, Medicare is by definition involved, and they may get the government involved by way of the U.S. Attorney’s office. There are very strict procedural requirements that are required to state a healthcare fraud action.

1:25 How Do Health Insurance Companies Detect Fraud? Procedural Requirements To File A Fraud Case

The relator has to file an affidavit describing the fraud. It has to be in-depth. It has to be material. The relator practically has to have an almost complete knowledge of every aspect of the fraud to state a claim in today’s world because there’s some case law out there that makes these cases even more challenging. Once the relator provides the disclosure, the matter is initially filed in the federal district court under seal where no one has access to it.

1:54 What Happens After The Affidavit Is Filed?

That occurs for at least six months so that the government can investigate the claims. I say at least six months, under the statute it remains under seal for at least sixty days. The government can virtually never investigate these matters in sixty days, so it’s very common to request consent orders to extend the seal over a prolonged period of time.

I’ve got one fraud case now that’s been under seal since 2017, which was four-plus years ago, and we’re still waiting on the government to complete their investigation.

2:34 After The Investigation

But again, it stays under seal for purposes of confidentiality and allowing the government to do an in-depth investigation. At that point, the government makes a decision as to whether they want to intervene and move forward on the case themselves or at all times, the relator has the opportunity to do it his or herself. That involves the virtual necessity of an attorney who understands healthcare fraud.

Again, find someone who’s experienced, who knows what they’re doing, and can work with you if you suspect you’ve been the victim of fraud.

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