Health Insurance Fraud

Working in the Medical Field has taught me the importance behind verifying information. In healthcare it is imperative to verify a members identity as well as medical benefits, to ensure that the physician and/or office gets reimbursed for services rendered.

On a daily basis I encounter patients that would like to be seen by a physician but they can not provide the office with a valid photo id. It is essential that we verify the patients identity before their visit in order to confirm that the individual insured is correct as well as verifying a correct billing address for claim purposes. If a patient is unable  to provide a id, our office has the right to deny services and refer them to an outside facility, such as a local hospital.

Since the downfall in the economy there has been high volumes of insurance fraud reported. Cases

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have been documented where patients allow other "un-insured" individuals use their medical insurance card to receive services, for a small "fee." Thus, greater measures have to be taken in order to control this growing issue.

Responsibly falls back on the facility and/or office front desk staff and billing staff to insure accuracy in billing claims, in order to submit accurate patient information.

I interviewed, Jade Shaw, a Clerical Administrator at MHCA (abbreviated for privacy) on measures being taken at the medical facility in which she is employed.

Interview Questions:
1.  What forms of identification are required at MHCA for new patients?
- "Here at MHCA we require that all new patients present the front desk with a valid photo id along with their insurance card during check in."

2. What types of identification are acceptable?
-"We accept drivers licenses, state issued identification cards and passports. Rather anything with a picture id, where we can match the patients name and the name on the insurance card with the patient along with being able to verify their face by photo."

3. What if a patient is unable to present a form of id to your office?
-"We advise them to reschedule when they have proper documentation to verify their identity or either refer them to a local hospital, in an emergency situation."

4. How does your office keep record of the patients id and insurance card?
-"In the previous years our office would make a xerox copy and file it in the patients medical chart. Now, with advances in technology our office now has the resources to scan electronically the patients id and insurance card. This makes it easier for verify a patients information during check in."

5. Would you say that the measures being taken are reducing account of insurance fraud?
-"I would have to say that our office has not had any incidents of insurance fraud because of our pre-cautious measures that we are taking in efforts to prevent it. Not saying that it could never happen, but we keep an open eye in order to prevent errors." 

(Interview Concluded)

In brief, insurance fraud is an issue that needs to be addressed and monitored closely. Consequences could result in physicians loosing their licenses as well as employees loosing their job. It is a chain of command that verifying a patients identification goes through and someone should catch the errors. Beginning with the front desk, as it works it way through to the physician.

Imagine the physician coding the wrong diagnose and procedure code for a patient because of a case of insurance fraud. Once the physician codes patients fee ticket and that trickles through to the billing department who then files it to the insurance company, the insurance company verifies the diagnosis and procedure codes. Insurance companies may even request for a physicians clinical notes on the patient from a specific period of time in order to verify that the claim was billed correctly before the insurance company agrees to pay for a procedure.

Working in healthcare requires attention to detail. You are handling sensitive patient information. There is no room for error!

Works Cited:

Shaw, Jade. Personal Interview. 05 Nov 2013.