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 the Complex Financial Crime Program, and each of the FBI’s 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 (FDA), Drug Enforcement Administration (DEA), Defense Criminal Investigative Service (DCIS), Office of Personnel Management-Office of Inspector General (OPM-OIG), and Internal Revenue Service-Criminal Investigation (IRS-CI), 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. The Bureau also 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 is important to know who you are 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 material 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 your knowledge is to review the explanation of benefits forms sent from your insurance company. These forms list the services and supplies supposedly provided to patients 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 is 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.
• When receiving medical supplies, be sure to check that you were sent what actually was ordered—for example, instead of a power wheelchair, you receive a much cheaper scooter. 
• Be aware of your surroundings in medical facilities. For example, when completing a physician visit, be wary of a medical office that lacks normal medical equipment, or if personnel fail to conduct normal patient health checks, like taking your temperature and blood pressure.

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