Health Care Fraud Overview

Health Care Fraud Overview

The FBI is the primary investigative agency involved in the fight against health care fraud with jurisdiction over both federal and private insurance programs. Health care fraud investigations are considered a high priority within our Complex Financial Crime Program, and each of our 56 field offices has personnel assigned specifically to investigate health care fraud matters. 

The Bureau leverages its resources in both the private and public arenas through investigative partnerships with other federal agencies such as Health and Human Services—Office of Inspector General (HHS-OIG), Food and Drug Administration, Drug Enforcement Administration, Defense Criminal Investigative Service, Office of Personnel Management-OIG, the Internal Revenue Service-Criminal Investigations, along with various state Medicaid Fraud Control Units and other state and local agencies. On the private side, the FBI is actively involved in the Healthcare Fraud Prevention Partnership, an effort to exchange facts and information between the public and private sectors in order to reduce the prevalence of health care fraud. And, the FBI maintains significant liaison with private insurance national groups, such as the National Health Care Anti-Fraud Association, the National Insurance Crime Bureau, and private insurance investigative units.

How criminals steal your information

 Beneficiaries should always be aware of potential fraudulent activities when dealing with medical providers via the Internet and during their normal daily activities. It’s important to know who you’re dealing with and why since many health care fraud scams involve the theft of patients’ medical information which is then used in schemes to obtain reimbursement for services and goods not provided.

Here are some of the most common methods used by criminals to fraudulently obtain patient insurance information:

• Providing an inducement, such as money or a gift, to beneficiaries to visit a location (normally medical clinics) where identities are obtained when the patient signs in.
• Obtaining patient information when patients obtain a free screening, a method frequently seen at health fairs.
• Inducing medical personnel with access to patient insurance information to copy the information and provide it to those involved in fraud schemes.
• Purchasing the information from others involved in fraud, including owners of fraudulent companies and marketers of stolen patient and physician billing information.

One of the most effective ways to determine if insurance information is being used without the knowledge of the insured is to review the explanation of benefits forms sent from their insurance company. These forms list the services and supplies supposedly provided to the patient from medical providers. If any billings are suspect, immediately contact the insurance company.   

Protect yourself

Here are several tips on protecting your information—and yourself—from unscrupulous heath care fraudsters: :

• Safeguard insurance cards and benefit information. Make sure there’s a legitimate reason to provide your insurance card or insurance information to others, and be especially vigilant if your information is requested when services are offered for free, or any offers are made during telemarketing calls.
• Be aware of gifts, or other inducements, from visiting medical providers. Don’t accept unnecessary equipment or products, and report any suspicious or unusual activity.
• Be careful when receiving medical supplies that you actually get what was ordered—for example, instead of a power wheelchair, you receive a much cheaper scooter instead.   
• Be aware of your surroundings in medical facilities. For example, be wary of if you completing a physician visit at a medical office that lacks normal medical equipment and its personnel don’t conduct normal patient health checks like taking your temperature and blood pressure.

If consumers suspect fraud, contact your health insurance company (most have toll free numbers to report fraud). Medicare fraud can be reported to 1-800-HHS-TIPS (1-800-447-8477). You can also contact your local FBI or HHS-OIG offices or your state’s Medicaid fraud office.