Health care plans that have recently launched health care fraud alerts on their websites have been inundated with calls from people who believe they have been defrauded.
The problem is, there is really no way to tell how fraudulent an email or fax is unless it comes from an actual fraud victim, and the emails and faxes often don’t contain any specific details about what the individual had done or didn’t do to get the benefits they got.
“They might say they sent an envelope full of money or something like that,” said Jennifer O’Neill, senior counsel at the Center for Effective Government, which has a national database that identifies fraud cases in the private sector.
But that’s not enough for some fraud detectives.
“It’s really hard to distinguish fraud from a false claim,” O’Neil said.
“So they call in the fraud team and say, ‘Well, we’ve got a person in our network who’s been a victim of fraud and they’ve said something that looks suspicious.'”
That’s when the fraud detective, known as a fraud analyst, will get on the phone and start looking into the claims.
And that person is usually a former employee or former contractor.
If the fraud analyst is convinced that someone has been defrauding the plans, he or she will then send a call to the plan’s fraud hotline.
“The fraud analyst will go in and say what happened and then the call goes out,” O. Michael Biederman, senior vice president of marketing and public relations at Humana Health Plans, said.
The fraud analyst would then try to find the original caller, a person who may have been the fraud victim in the first place.
“That person could be a contractor, an employee, or even a former contractor,” Biedermansaid.
“Sometimes the fraud investigator may have to go through an investigation process, where he or her will look into the facts of the case to figure out who the person is.”
The fraud investigator will then look into whether the caller has been involved in any fraudulent activity before.
“If you’re looking for fraud, it’s pretty easy to find fraud,” Biesaid.
The fact that a fraud hotline has been created to help victims is a good thing.
But in the case of a health care claims scam, the fraud hotline is just one of many layers of protection the fraud expert has to look at in order to spot potential fraud.
“There are lots of different layers of defenses that have to be used,” said O’Brien.
“We also have a team of attorneys, who will be reviewing the claims and determining if there’s fraud or not,” he said.
And when the claims are confirmed, it can take days or even weeks before the fraud investigation is complete.
“A lot of times, the claims have been approved and approved, and there’s no fraud involved,” said Biedemansaid, adding that it takes months to review every claim and review each claim for fraud.
That’s why it can be challenging to get to the bottom of fraud claims that don’t actually involve fraud.
In the meantime, the consumer should not take any health care claim for granted.
“People should be aware of the potential risks and should take steps to be proactive and to protect themselves,” Bredermansays.
“But if they’re not, then they shouldn’t take any of their health care coverage for granted.”Read more