Weather | Sports | Forums | Comics | Classifieds | Calendar | Movies
Associated PressHealth care fraud fighters work with state and federal officers to try to erase the crimes.
TAMPA - Health care fraud will cost Americans at least $50-billion this year, but insurance companies said Wednesday they are working with state and federal authorities to step up enforcement.
The crimes are committed by a small percentage of doctors and other health care providers, but they can cost the average consumer as much as $1,200 a year in higher premiums, said Bill Mahon, president and CEO of the National Health Care Anti-Fraud Association.
"It's a crime that the system can't tolerate economically for much longer, and it's a crime, that by it's nature can't be tolerated morally," Mahon said Wednesday as insurers and investigators from around the country gathered at the Tampa Marriott Waterside Hotel as part of the association's annual training conference.
Mahon said most fraud cases fall into four categories:
A doctor or hospital bills for treatment that never happened, such as X-rays not taken or blood work never done.
The health care provider "upcodes" by billing simple procedures under more expensive codes. This can include everything from a doctor getting an extra $100 by billing a regular office visit as an extended new patient visit to a hospital billing simple pneumonia under complex viral pneumonia.
A doctor disguises a procedure that is not covered, such as claiming cosmetic nose surgery as a deviated septum repair or a tummy tuck as a hernia.
A doctor performs an unnecessary procedure.
"In heath care fraud, the perpetrator is sending you the crime and daring you to find it," said Michael Stergio, head of special investigations for Aetna Inc.
Investigators say the best way find the crimes is to share information between companies. The association has created a massive database in which insurers and investigators can look for trends and meet regularly to compare various schemes.
Federal penalties can land a first-time offender in prison for up to 10 years, but many cases only reach the state level, in which penalties vary greatly by region, said Lt. Ira Warder, a fraud investigator with the Florida Department of Financial Services.
Warder said he's seen a family who set up fraudulent clinics receive more than 10 years in prison, but he also knows of a dentist who defrauded insurers out of more than $2-million a year yet received just three months in county jail.
Sometimes prosecutors will have to forgo prison time to negotiate restitution, he said.