Medical Billing Fraud: What You Can Do About It

by Holly R Brady on October 15, 2013

Imagine one day receiving an Explanation of Benefits statement and discovering that your doctor billed for a medical procedure that you don’t remember having done. You then realize that this isn’t the first time your doctor has done this. So, you call your doctor’s office and you’re told that this is how your doctor bills to get your insurance company to pay for his services. Your doctor could be committing medical billing fraud. 

Private and public insurers are out to stop medical billing fraud by health care providers who deliberately bilk insurers out of millions of dollars each year. In addition, the federal government is now putting a priority on prosecuting cases of fraud in Medicare and Medicaid claims, which contribute to rising healthcare costs and waste of taxpayer funds.

Something’s not right here…
You don’t have to be in the medical field to know that something is not right when you receive EOB’s listing services for which you were billed yet you did not receive.
You should become suspicious, if any health care provider:1. pressures you to undergo tests or treatments that you don’t believe are necessary. This is especially a red flag if your doctor says not to worry because your insurance company will pay for them.

2. recommends surgeries to rectify questionable medical conditions that you are not certain that you have.

3. waives your co-payment and over-bills your health care insurer or asking for a co-pay when your benefit plan has already made the payment.

4. charges for medical procedures that were done by an associate or a nurse.

5. overcharges an insurer or Medicare for medical devices and equipment.

Medical billing fraud also occurs when you discover that your health insurance is maxed out and you have not received any recent services. It’s possible that you have been the victim of medical identity theft. This occurs when doctors or other health care providers steal your name, Social Security Number, and bill your health insurer for fake treatments or sell your personal information to strangers who receive free services under your policy.

Steps to take if you suspect fraud:

a. Patients, employees, or subcontractors who suspect a health care provider is committing fraud, can contact the health insurers with your concerns. The federal government also encourages those with evidence of Medicare fraud, to come forward as “whistleblowers” and file “Qui Tam” lawsuits under the federal False Claims Act.
b. A “Qui Tam” lawsuit is usually brought by employees or former employees of a health care provider. The lawsuit is filed on behalf of the government with the goal of recovering money the government paid out based of false claims. Individuals or health care professionals willing to take on the risk should first consult with an experienced Qui Tam attorney, advises the website
c. If you suspect your provider of medical billing fraud, it’s never a good idea to just go along with it, even if it seems it will save you money in the short term. If the insurer discovers the fraud later, they can try to recover the appropriate amount that should have been paid, and they may discontinue coverage and certainly won’t work with that provider.
d. Billing fraud contributes significantly to insurer overhead, and these costs are passed on to plan participants in the form of higher premiums and co-pays. More importantly, a provider who is gaming the system is clearly putting profit above quality patient care, and you can’t be sure that you are receiving appropriate and timely treatment.
The government does more than just give a pat on the back as a way to commend whistleblowers who have the courage to stop medical fraud. Whistleblowers who win their case receive 15 to 30 percent of the money the government recovers from the health care provider.
You can find more information about the criteria for filing a federal Qui Tam lawsuit at Because attaining whistleblower status is complicated, an attorney can tell you whether you have a case based on your evidence. If you have a case, the Qui Tam attorney will file the lawsuit “under seal,” which means that you will remain anonymous throughout the investigation. Should the U.S. Justice Department intervene, it will become the lead attorney against the health care provider. If the government does not join in, you can continue your lawsuit.
Holly R Brady

Holly R Brady

Holly R. Brady first began blogging while studying for her psychology degree and enjoys writing on legal and lifestyle topics. When she isn’t writing she likes swimming and reading, as well as taking long walks with her two Irish Setters.
Holly R Brady

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