insurance fraud


Ellen Snyder, MSW decided to simplify some of her administrative tasks by routinely waiving the insurance co-payment for her clients. Most of her clients had 80% of charges covered by their insurance. Ms. Snyder felt that billing and collecting the “per-session” co-payment was more trouble than it was worth, so she would accept the insurance                                                                             payment as total compensation. ​

What are some examples of insurance fraud?

  • ​Submitting a claim for services that were not rendered can be insurance fraud. If a patient misses an appointment without canceling, many practices bill for that missed appointment. However, the practice should NOT bill the patient’s insurance carrier unless the patient’s contract allows for reimbursement for services not rendered.
  • Signing insurance forms for services performed by another person not authorized to receive reimbursement. Such an arrangement is typically seen when a provider is working in a private practice while awaiting licensure. This option is acceptable ONLY if the patient’s insurance contract covers the services of unlicensed providers.
  • Taking a reduced payment for services is yet another form of fraud.  In the above scenario, Ms. Snyder has every right to waive a co-payment or reduce a fee for self-paying patients only.

Medical Billing Tip:
The best risk management technique for liability related to fee collection, is to be familiar with your patient’s insurance contracts and to bill accordingly. The variety and complexity of insurance coverage have lead many practices to hire a professional billing service for these tasks. Additionally, establish a policy for missed appointments and any fee reductions. Never base this policy on the availability of insurance coverage and follow it consistently.

Resources & Credits:

Check out our Medical Office Workflow, Medical Billing Process, Contact Us, Prior Authorizations, Medical Office Checklist, Patient Deductibles, Global Maternity Part 1, Global Maternity Part 2, Global Maternity Part 3, or Global Maternity 4 page.

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