How it Works: Health Insurance Fraud Investigation 

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…

Did you know that nurses don’t just defend public health through direct patient care – they’re also crucial team members on the front lines fighting fraud, waste and abuse? Their knowledge represents an irreplaceable asset in any solid medical review team. Medical review is the clinical review of health records, medical bills and supporting data….

The Government Accountability Office (GAO) made headlines recently when sharing news that 11 of 12 fictitious applicants obtained coverage for health insurance through the Federal marketplace. GAO targeted the Federal marketplace with secret shopping – constructing fictitious applicants who should not have received health insurance. The secret shopping applicants provided invalid Social Security information or…

Since the late 20th to early 21st century, reports such as “To Err is Human” by the Institute of Medicine have been published and have advocated the adoption of electronic health records (EHRs). EHRs offer tools to mitigate human error, be a medium to share personal medical records securely across the country, establish electronic communications…