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NJ Told To Beware Of Healthcare Insurance Fraud

Be alert for healthcare insurance fraud. That’s the warning issued today by the head of New Jersey’s Department of Banking and Insurance (DOBI).

This type of fraud can include misrepresentations made to consumers during the sales process, submission of claims for services that were either not provided to consumers or misrepresenting the extent of services provided.

“Consumers can never let down their guard when it comes to healthcare insurance fraud,” says DOBI Commissioner Ken Kobylowski. “We cannot afford to ignore fraud’s red flags. Always review a bill issued to your carrier. Even when a medical provider submits it on your behalf, your insurer provides you with an Explanation of Benefits (EOB). Make sure services provided to you are the services described in the bill and the EOB. Report any discrepancies to your insurer immediately.”

Make no mistake. This type of fraud is not rare. The FBI estimates that health care fraud costs the country an estimated $80 billion a year. That cost directly translates into higher insurance premiums for all consumers.

Recent cases have involved false or inflated charges for services that were not performed. Submitting a false claim form to a health care insurer is a violation of the New Jersey Health Care Claims Fraud Act. Anyone who break this law faces a fine up to $150,000 and a possible sentence of three to five years in jail for each false claim.

“If you are not certain about something you see in that statement, do not be afraid to question it,” urges Kobylowski. “Also, if you are not sure about the medical necessity for a prescribed service, you should ask for a second medical opinion.”

Kobylowski is offering tips to help you avoid healthcare insurance fraud in claims:

  • Review your bill from your health care provider and your EOB from your insurance carrier carefully. Look for charges listed to make sure they were received;
  • Watch for erroneous, repetitive listing of procedures for the same service;
  • Verify that the doctor requested the services listed;
  • Guard your insurance information and make certain that only your providers and carrier have this data;
  • Only go to doctors and other medical providers on referrals by people you know and trust. Do not accept money for referrals and watch out for those who may earn cash by sending you to a certain provider. Making referral payments in exchange for patient tests and treatment is illegal.
  • Make sure you tell the truth when filing an insurance application and claim. It is illegal to knowingly make an oral or written statement which is false or misleading in order to obtain health insurance.

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