The Coalition Against Insurance Fraud reported $36.3 billion lost to healthcare fraud in 2023—a vast increase compared to previous years. The state of Georgia specifically has seen a particularly sharp spike in reported medical fraud cases in 2023. As a result, the state has been named number five in the list of top states for fraud and has driven up overall medical insurance premiums across the region.
Here, we outline the different types of medical scams, the steps you can take if you’ve witnessed or experienced this behavior, and what Central’s Anti-Fraud team is doing today to combat medical frauds nationwide.
3 Different Types of Medical Frauds
Central’s Director of Anti-Fraud and Recovery, Jeff Lieberman, has seen thousands of medical fraud cases in his career. Part of what makes these cases so hard to mitigate, he says, is that they can take many different forms depending on the situation.
At the heart of most medical frauds are typically one of three individuals: the patient, the medical professional, or the attorney.
Patient-Led Medical Frauds
In the case of a patient, an individual might invent or inflate the extent of an injury or issue to receive additional money for their care. Others may send claims for medical treatment that never existed to pocket the money from their carrier.
Real-World Example: This article published on June 1, 2023, on an Atlanta online news source dives into an insurance fraud case committed by four women in Georgia. According to the piece, the ringleader of this group “filed 52 different claims and submitted 36 forged documents as evidence” to their insurance carrier, which led to her collecting more than $21,000 from her carrier over three years. The special agents from the state’s Criminal Investigations Division stepped in to mitigate this scam, resulting in the anticipated arrest of the four women.
Doctor-Led Medical Frauds
In some situations, it’s not the patient exaggerating the extent of their injuries but a medical professional. In these instances, the individual is likely inflating the charges, performing unnecessary treatments and tests, or billing for services never rendered.
Real-World Example: This press release published in May 2023 by The United State’s Attorney’s Office: Northern District of Georgia outlines the case of a pain management and ambulatory surgical center that submitted $625,000 worth of improper claims for services that were medically unnecessary.
Attorney-Led Medical Frauds
Though the least commonly understood approach to medical frauds, Lieberman explains that attorney-led schemes occur more often than you might think.
“Relationships between attorneys and medical providers can lead to larger damage awards or settlements, positioning both for increased financial gain,” he says.
In this scenario, a provider might agree to provide treatment to an injured person, expecting to receive payment from an anticipated settlement or verdict. When medical providers have a financial interest in the outcome of a claim, they may end up providing excessive or unnecessary medical treatments to increase the value of a client’s case.
“The attorney then uses the exaggerated medical evidence to demand a higher settlement,” he says.
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How can I tell if my provider might be committing medical frauds?
Since cases of medical fraud can look different depending on the situation, it’s important for individuals to stay aware and on guard for these types of schemes. Below, we outline five key red flags that may signify your provider is fraudulent:
- They recommend multiple medical tests. There are many legitimate reasons a doctor might conduct various tests and procedures to help determine what’s ailing you. However, if you feel confident the tests you’ve already done have determined the root cause of the problem, but your doctor continues to recommend more, this might be a sign they are trying to run up your insurance bill.
- They immediately push for surgery. If you have any doubt the surgery your doctor is recommending is necessary, always seek a second opinion. If the other doctor is surprised by the surgery recommendation or suggests a less invasive—and less costly—option that will be just as effective, your first provider may be running a scam.
- Your explanation of benefits shows unrealistically high charges. A patient will receive an explanation of benefits from their insurance carrier after a provider submits a claim to their insurance carrier. Be sure to review these documents closely and confirm that your provider a) isn’t charging an unrealistic amount for what you had done and b) isn’t adding unpursued treatments, medicines, or procedures to your bill.
- The medical provider immediately directs you to an attorney. The involvement of an attorney at this stage is a red flag, especially if the attorney begins providing advice as it relates to your care, benefits, or claims. In many cases, an attorney may refer you to a medical provider you either never see in person or operates out of a building that doesn’t appear legitimate. Both of these should be warning signs that there is a likely scam taking place.
- You never see your healthcare provider in person. There are many legitimate online healthcare options today—from apps allowing you to text a therapist to online treatment delivery options. However, if an online provider recommends a costly approach to treatment, such as surgery or ongoing care, you want to think twice before jumping in. Instead, get a second opinion from a reputable provider in person to ensure you’re not being scammed.
What do I do if I think my doctor is fraudulent?
It can be overwhelming and disappointing to discover someone you’re supposed to be able to trust has been scamming you and your insurance carrier with medical frauds. However, if you experience any of the red flags above, there are steps you can take to help state- and carrier-level fraud investigation teams mitigate the crime at hand.
- Step #1: Alert your carrier. The moment you start feeling like something fishy might be going on with your provider, get in touch with your insurance carrier and fill them in.
Keep in Mind: Even if you’re unsure, it’s better to alert your carrier so they can monitor the provider’s submitted claims for unusual activity.
- Step #2: Document everything. Do your best to gather and document everything from your experiences with your provider. Fraud investigative teams can use receipts, emails, explanation of benefits documents, pamphlets they’ve passed along for suggested treatment, and more to help track patterns and identify scams.
- Step #3. Find a more reputable provider. One of the most disheartening aspects of medical frauds is those who experience it are often left still needing medical care long after their doctor is found guilty. Yet, it can be difficult for a patient to trust a new provider after falling victim to a medical scam. Lean on your insurance carrier to help you find a provider in good standing and continue your treatment with peace of mind.
What is Central’s Special Investigative Unit doing to prevent cases of medical frauds in Georgia?
Led by Lieberman, Central’s Anti-Fraud team is working tirelessly to help identify, mitigate, and prevent all kinds of insurance fraud cases nationwide.
By working closely with law enforcement and the Department of Insurance and forming strong partnerships with external partners like consumer protection agencies, the Better Business Bureau, and the Federal Trade Commission, Lieberman’s team has made great strides in cutting off scams at the source.
Did You Know: At the heart of this work is the team’s industry-leading fraud analytics program, which layers historical data with various external sources and AI functionality to help track patterns among fraudsters and stop insurance schemes in their tracks.
This cutting-edge team has a special interest in stopping medical frauds within the states most at risk—including Georgia.
“One of the most common types of fraud we’re seeing in Georgia are medical build-up schemes, so that’s what our team has been addressing first,” Lieberman says. “But we’re not stopping there. We’ve written articles for Georgia publications, and I just did a podcast with the Georgia Medical Association specific to what we’re seeing in Georgia as it relates to these schemes. We’re going to get the word out that this is happening so innocent people don’t fall victim to these schemes.”