Health Care Fraud
After reading the online article Monday night, I posted a comment on Huckleberries Online, the weblog managed by The Spokesman-Review associate editor and columnist Dave Oliveria. Shortly thereafter, another commenter characterized my comments about the Spokane mayor's response as a cheap shot. That's fine, but then in a followup post, the same commenter asked, "... who got overbilled? Premera Blue Cross?"
That's really a great question, because it implies that overbilling insurance companies is tolerable if not completely acceptable. No, it is neither tolerable nor acceptable, and if it is done knowingly and intentionally, it can be insurance fraud. And apparently insurance fraud is a pretty big deal in Washington State. This year's state legislature saw the need to propose the state’s first fraud bureau and add a fraud prosecutor.
But insurance fraud is not just a Washington State problem. It's also a national problem. Take a look at the Federal Bureau of Investigation's Financial Crimes Report to the Public released in May 2005. Pay particular attention to the Health Care Fraud section, and note the "Ambulance Initiative" under "Significant Cases."
Since Medicare is a major insurer providing compensation to claimants, it's also a good idea to learn something about Medicare fraud.
Local agencies (e.g., fire departments) administering medical transportation contracts need to better understand what to look for to prevent mixups or outright fraud. The September 1, 2000, issue of Fire Chief magazine explained to its readers How to avoid common ambulance billing pitfalls. It's an article worth reading.
Was the commenter wrong when s/he implied that overbilling was acceptable or at least tolerable and we should just move on after the offenders make restitution and possibly pay a punitive fine? Yes, but according to a Coalition Against Insurance Fraud report, s/he's not alone in thinking that. That acceptance is one reason why health care fraud is on the increase.
Unless competent, experienced fraud investigators and auditors "follow the money", we won't know for sure if health care overcharges are just mistakes or crimes. The public, the insurance industry, and the health care providers are entitled to know. It's our money.