How it Works: Health Insurance Fraud Investigation 

Posted by IntegrityM | | Investigations

The U.S. government won over $5 billion in healthcare fraud cases in 2021 according to the HHS Annual Report. That’s a huge number—but it only covers the dollar amount of fraud successfully found through investigations and reporting. Combatting the billions of dollars in fraud each year is the work of specialized investigators committed to keeping our healthcare infrastructure strong. 

Health insurance fraud investigations look to identify suspect or misleading billing on insurance claims, such as: 

  • Submitting claims for services not rendered 
  • Unbundling services 
  • Upcoding 
  • Altering claims submissions  
  • Kickbacks 
  • Providing services by a non-qualified provider 
  • Billing incorrect codes  
  • Billing for medically unnecessary services 

The case begins 

Catching healthcare fraudsters is a collaborative effort. Investigations are often the work of multiple agencies, such as private sector contractors, the Department of Justice, FBI, HHS and other law enforcement.  

A fraud case can be triggered in many ways, some of the most common are: 

  • Beneficiaries identifying suspicious billing  
  • Referrals from law enforcement, CMS or other agencies 
  • Through data analysis or monitoring of submitted claims

The allegation is turned over to fraud investigators who are tasked with determining if fraud, billing waste or abuse of billing exists. 

Next steps 

The healthcare fraud investigator may then proceed with further tasks, such as reviewing the complaint or allegation, completing a thorough background analysis, completing data analysis of claims, interviewing beneficiaries, interview providers and completing a medical review of sample claims to determine if fraud, billing waste or abuse of billing exists.  

As part of an investigation, actions may be taken to include overpayment identification/refund requests,  conducting provider education, revoking provider healthcare program billing rights, or criminal investigation by law enforcement authorities. 

With billions of dollars at stake each year, combatting health insurance fraud is critical. IntegrityM investigators provide diversified expertise in the identification and resolution of healthcare fraud, waste and abuse. Connect with us today to speak with one of our experts. 

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