Why It's Important to You
Fraud affects each of us. How? Insurance premium rates are set, in part based on the cost of benefits that are paid. Fraud needlessly increases the amount of benefits that are paid out...in turn, raising the cost of insurance — the premiums — each of us pay.
Health insurance fraud involves an intentional deception, concealment, or misrepresentation that an individual or entity makes knowing that it could result in some unauthorized benefit to the individual, entity, or some other party.
What We're Doing About It
We fight fraud as part of our effort to assure that our premiums are kept as low as possible.
Medico Insurance Company has a Special Investigation Unit (SIU) that investigates suspected fraud and ethics violations and takes appropriate action, including referrals to law enforcement officials. If you suspect someone may be committing a fraud or ethics violation against our company, contact our Fraud and Ethics Hotline at 1-800-678-6685, or visit our EthicsPoint Web Reporting System page. All calls and website inquiries will be handled discreetly and confidentially.
Five Elements of Fraud
The legal system has generally defined fraud to include five basic elements. To be considered fraud, all five elements must be present.
- False Representation: This often takes place when a claim is submitted, and the claim includes charges for services that were never rendered, a patient that was never seen, false diagnoses, etc.
- Knowledge of its Falsity: The party submitting the information has knowledge of its falsity.
- Intent to Defraud: The party submitting the information is doing so with the specific intention of defrauding a victim.
- Justifiable Reliance by the Intended Victim: The payer pays based on the reliance that the claims and supporting documents are valid.
- Resulting Damage: Monetary or other loss resulting from the fraudulent submission.
Examples of Insurance Fraud
Here are a few examples of the many ways insurance fraud can occur:
- Intentionally billing for services, procedures and/or supplies that were not rendered.
- Intentional misrepresentation of any of the following:
- The nature of the services, procedures and /or supplies provided.
- The dates on which the services and/or treatments were rendered.
- The medical record of service and/or treatment provided.
- The condition treated or diagnosis made.
- The charges for the service, procedure and/or supplies provided.
- The identity of the provider or recipient of services, procedures and/or supplies.
- The deliberate performance of unwarranted or non-medically necessary services for the purpose of financial gain.
How You Can Help Prevent Fraud
As the person most knowledgeable about your medical treatment, you should review medical bills and claim payments for irregularities such as:
- Charges for medical treatment which was not performed.
- Charges for medical treatment by physicians you did not see.
- Incorrect dates of treatment.
As an informed consumer, you also need to clarify with your medical provider the need for:
- Referrals to other physicians or providers who are not specialists.
- Excessive treatment for minor injuries or illnesses (repeated follow-ups when illness is gone or injury is healed).
- Medical treatment which does not appear to be related to, or consistent with your medical condition.