Healthcare Fraud
The National Insurance Crime Bureau estimates the average
American household pays $200 in additional premiums per year to make up for
insurance fraud and abuse. Fraud and abuse continues to be a serious
contributor to the high cost of healthcare. By its nature, the amount lost can
only be estimated. A 1996 report by the General Accounting Office estimated
that fraud accounted for 10 percent of the nation's healthcare spending. If
that 10 percent figure holds true today, the annual total cost of healthcare
fraud would approach $100 billion.
The mission of Medical Mutual of Ohio's Financial Investigations
Department is to detect and investigate all unlawful activity directed at the
corporation's assets and to seek criminal, civil and administrative remedies
for the benefit of the company's policyholders.
Medical Mutual is proud of its accomplishments in fighting
healthcare fraud and abuse. We encourage our members to join us in this
worthwhile effort.
Identifying Healthcare Fraud
An effective way for you to identify healthcare fraud is by
taking the time to read the explanation of benefits that Medical Mutual sends a
member after processing a claim. Fraud can be identified by asking the
following questions:
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Does your explanation of benefits form only show payment for services that were
provided to you or your dependents?
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Do the date of service and the name of the facility or doctor that provided the
service match your records?
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Does the type of service provided on your explanation of benefits match exactly
the service that was provided?
If you can answer NO to any part of the above
questions, there is a possibility that fraud has been committed.
A difference between your records and the explanation of
benefits does not necessarily mean fraud has been committed. Notify Medical
Mutual's Financial Investigations Department where an investigation will
determine if fraud, abuse or waste has been committed.
What is Fraud?
Healthcare fraud is intentionally making or
causing to be made any false statement or misrepresentation on a claim,
billing, receipt or any other associated materials with the intent of causing,
or causing to be made, unwarranted payment in part or in whole.
Abuse describes incidents or practices, which
are not usually fraudulent, but are inconsistent with accepted and sound
medical, business or fiscal practices.
Medical Mutual's Record
Forming its Financial Investigations unit in 1983, Medical
Mutual of Ohio is a pioneer and industry leader in the area of investigating
healthcare fraud. Using specialized investigative techniques along with
technological advances the company has accomplished an impressive record in the
fight against healthcare fraud:
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Saved customers almost $50 million since 1983
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Recovered $5.4 million in 2005
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Produced more than 600 indictments since 1983
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Investigates, on average, 120 cases per year