How to Report Health Insurance Frauds 2022

Trying to make sense of insurance claims and billing can be challenging, as can navigating the healthcare system. The situation becomes significantly more complicated when human error and deliberate fraud schemes are included. Later in this article we will treat How to Report Health Insurance Frauds.

It is simple to understand how, amidst all the legalese and bureaucracy, customers and CPAs(Certified Public Accountants) can miss blatant incidents of fraud.

However, CPAs can take measures to assist their clients in guarding against health care fraud. This includes assisting clients in spotting warning signs, instructing clients on how to avoid typical misuse techniques, and providing clients with information on how to report instances of fraud.

Because they frequently interact with clients and their finances, CPAs are in a good position to assist clients in preventing fraud.

According to a conservative estimate by the National Health Care Anti-Fraud Association, health care fraud costs the country roughly $68 billion annually. This is about 3% of the $2.26 trillion in health care expenditures. Other estimates vary as high as $230 billion, or 10% of annual health care spending.

Keep reading to see how to report health insurance frauds.


What is Health Insurance?

Before going into how to report health insurance frauds, let’s see what health insurance is all about.

Health insurance is a legal agreement. It commits an insurer to covering all or a portion of a person’s medical expenses in return for a premium.

More specifically, health insurance often covers the insured’s out-of-pocket costs for prescription drugs, medical procedures, and occasionally dental care. Health insurance can either pay the healthcare provider directly or compensate the insured for costs related to illness or damage.

Additionally, as a means of luring quality workers, it is frequently offered by employers as a benefit package. It comes with premiums partially covered by the company and frequently withdrawn from employees’ paychecks.

However, with some exceptions for company employees, the cost of health insurance premiums is deductible by the payer. Also, the benefits received are tax-free.

Keep reading to see how to report health insurance frauds.

How Does Health Insurance Work?

As mentioned earlier, navigating health insurance can be challenging. For the maximum degree of coverage, managed care insurance plans demand that policyholders receive their medical treatment from a network of predetermined healthcare providers.

Furthermore, patients are required to cover a greater portion of the cost if they seek care outside the network.

In some circumstances, the insurance provider may even outright decline to pay for services obtained outside of the network.

Numerous managed care programs examples are; health maintenance organizations (HMOs) and point-of-service plans (POS). They demand that patients select a primary care physician to monitor their care, provide treatment recommendations, and refer them to medical specialists.

Contrarily, preferred-provider organizations (PPOs) do not need recommendations but do have cheaper rates for using in-network doctors and other providers.

Additionally, insurance providers may refuse to pay for specific services that were obtained without prior authorization.

If a generic version of a similar drug is available for less money, insurers may decline to pay for name-brand pharmaceuticals. These guidelines should all be included in the documentation that the insurance provider provides and should be carefully read. Before making a significant investment, it is wise to verify with employers or the company itself.

Copays are fixed fees that plan members must pay for. Services like doctor visits and prescription drugs, deductibles.  All these must be met before health insurance will cover or pay for a claim.

Coinsurance is a portion of healthcare costs that the insured must pay even after they’ve met their deductible. These are other features of health insurance plans that are becoming more common.

Higher deductible insurance policies typically offer lower monthly premiums than low deductible policies. When comparing plans, consumers must balance the advantages of lower monthly payments with the possibility of high out-of-pocket costs in the event of a serious illness or accident.

Keep reading to see how to report health insurance frauds.

Check out: Top 5 Best Small Business Health Insurance In Washington

What is Health Insurance Fraud?

Let’s check this out before we check how to report health insurance frauds. Health insurance fraud, prescription fraud, medical fraud, and “snake oil” marketing are all examples of health care fraud.

When a business or an individual defrauds an insurer or government health care program, such as Medicare (United States) or analogous State systems, this is known as health insurance fraud.

This is done in a variety of ways. Those who commit fraud are constantly looking for new ways to get around the law. The False Claims Act allows for the recovery of fraud damages.

In this type of fraud, a health insurance company is given incorrect or misleading information. This is done in an effort to get them to pay unauthorized benefits to the policyholder, another person, or the business providing the services. The insured person or the company providing the medical services may both be guilty of the violation.

A single customer may defraud a health insurance company by:

  • allowing another person to use his or her name and insurance details to get medical care
  • taking use of benefits to pay for medications that were not prescribed by his or her physician

Keep reading to see how to report health insurance frauds.

Types of Health Insurance Fraud

There are several different schemes used to defraud the Health care system. Check them out before going through how to report health insurance frauds.

  • Billing for services not rendered
  • Upcoding of services
  • Upcoding of items
  • Duplicate claims
  • Unbundling
  • Excessive services
  • Unnecessary services
  • Kickbacks
  • Copied and pasted entries into the medical record

Billing for services not rendered

Often done as a way of billing Medicare for things that never happened. This can involve forging the signature of those enrolled in Medicare, and the use of bribes or “kickbacks” to corrupt medical professionals.

Upcoding of services

Billing Medicare programs for services that are more costly than the actual procedure that was done.

Upcoding of items

Similar to upcoding of services, but involving the use of medical equipment. An example is billing Medicare for a power-assisted wheelchair while only giving the patient a manual wheelchair.

Duplicate claims

In this case a provider does not submit exactly the same bill. However, he changes some small portion like the date in order to charge Medicare twice for the same service rendered. Rather than a single claim being filed twice, the same service is billed two times in an attempt to be paid twice.


Bills for a particular service are submitted in piecemeal, that appear to be staggered out over time. These services would normally cost less when bundled together. However, by manipulating the claim, a higher charge is billed to Medicare. This results in a higher pay out to the party committing the fraud.

Excessive services

Occurs when Medicare is billed for something greater than what the level of actual care requires. This can include medical related equipment as well as services.

Unnecessary services

Unlike excessive services, this fraudulent scheme occurs when claims are filed for care that in no way applies to the condition of a patient, such as an echo cardiogram billed for a patient with a sprained ankle.


Kickbacks are rewards such as cash, jewelry, free vacations, corporate sponsored retreats, or other lavish gifts. They are used to entice medical professionals into using specific medical services.

Keep reading to see how to report health insurance frauds.

How to Report Health Insurance Frauds

There are numerous ways to report fraud situations. Patients and healthcare professionals are urged to get in touch with the FBI. Get in touch via their local office, phone number, or the online tips form.

However, individuals are urged to get in touch with legal counsel from a skilled firm. A firm that specializes in qui tam lawsuits under the False Claims Act.

Potential whistleblowers can be informed of their legal rights and protections. As well as what proof is required to make a strong case against the group responsible for the fraud by a competent legal team.

Reach out FBI through this link

Also read: 6 best Health Insurance in Maine

Conclusion on How to Report Health Insurance Frauds

The majority of health insurance plans offer particular benefits, and actions like overcharging for the services received deprive consumers of these benefits.

Because of this, health insurance fraud is a serious offense. Many states views it as a felony, much like all other types of insurance fraud. Infringers risk up to $50,000 in fines and up to four years in prison.

There are other more expenditures involved, including court fees and attorneys’ fees. Additionally, people found guilty of insurance fraud must live with the stigmas and restrictions associated with being a convicted felon.

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