Tuesday, January 20, 2009

$68 Billion Yearly: Medical Insurance Fraud

By Jen Lynch

To illustrate the escalating incidence of medical-related fraud, let me explain a recent case involving false injury claims. An employee of Mutual of Omaha was just sentenced to two years in prison for orchestrating false insurance claims with a policy holder in Vermont. This scheme started in 2001, and resulted in close to $1.4 million in medical payments over five years. The employee backdated each of the fraudulent claims to make it appear as though they happened at the time the client's policy was in effect. The policy holder received approximately $1,396,000 in the mail from Mutual of Omaha as reimbursement for the false medical expenses. The Mutual of Omaha employee was paid $95,600 by the client, for her assistance in the crime. This is just one example of the multitude of ways people are committing insurance fraud.

According to the Coalition Against Insurance Fraud, the following statistics are cases reported by the news media, by type of fraud, in 2008. (Click on the chart to see enlarged version)


The top two types of fraud are involved with healthcare. Surprising? The National Health Care Anti-Fraud Association states that the U.S. spends more than $2 trillion on healthcare annually, and in 2008, at least 3 percent of that spending, $68 billion, is lost to fraud every year. The problem with the statistics above is that they are only expected to increase in the future. Consumer attitudes towards insurance fraud are becoming more tolerant, and more people are expressing negative feelings about insurance companies.

The Coalition Against Insurance Fraud is asking that any new medical legislation introduced this year have strong anti-fraud provisions attached, and that all states adopt insurance fraud statutes. According to the Insurance Information Institute (III),  41 states and the District of Columbia have set up fraud bureaus to combat all types of insurance fraud. These agencies have reported increases in suspected fraud referrals, cases opened, convictions and court-ordered restitution. Hopefully these new agencies will help lower the outstanding amount of money lost to fraud, and help patch the holes in both the insurance and healthcare systems. 

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