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Healthcare Fraud

Healthcare Fraud

What is Healthcare Fraud?

  • Billing for Services Not Rendered
    • The most common health care fraud scheme involves a medical provider billing an insurance carrier for a service they never provided to a patient.
  • Upcoding
    • This healthcare fraud scheme involves a medical provider billing an insurance company for a higher level of service than what they actually provided. Upcoding could also include a medical provider exaggerating or falsifying a medical diagnosis so they can perform unnecessary and expensive medical tests and procedures.
  • Medical Identity Theft
    • Some patients have had their health insurance information stolen and used by criminals. Some doctors have also had their provider identification numbers stolen as well. In both circumstances, criminals use stolen information to submit fraudulent bills to health insurance carriers. 

The Role of the Ohio Department of Insurance Fraud & Enforcement

  • The Superintendent of Insurance is responsible for seeing that all insurance laws are enforced.
  • In order to effectively investigate allegations of agent misconduct and insurance fraud, the Fraud Division was created.
  • The division is designated as a criminal justice agency and is authorized to subpoena testimony and information, access law enforcement databases and share confidential information with other regulatory and law enforcement organizations.
  • Division investigators work with federal, state, and local law enforcement agencies, prosecutors, and government entities to bring charges against insurance agents, consumers, health care providers, and contractors who commit insurance fraud or engage in crimes associated with insurance.