Health care fraud more likely during the Holidays...Regence advises consumers to take charge and protect themselves

PORTLAND, Ore., Dec. 20 /PRNewswire/ -- Regence BlueCross BlueShield of Oregon, the state's largest health care insurer, is encouraging consumers, especially seniors, to be aware of fraudulent activities and to take steps to protect themselves from becoming victims of fraud this holiday season. The company offers several suggestions for how consumers can avoid falling for scams and frauds.

"We often see an increase in criminal and fraudulent activity of all kinds during the holiday season," said Alex Johnson, senior manager of the Special Investigative Unit at Regence. "People usually feel more generous during the holidays, and they're in the spending mode. Criminals take advantage of this."

In 2004, the Centers for Medicare & Medicaid Services stated that approximately $85 billion -- five percent of the $1.7 trillion in United States health care expenditures in 2003 -- was lost to fraud. According to the National Health Care Anti-Fraud Association, an estimated $100 million is lost every day on health care fraud.

Johnson, a former FBI special agent focusing on white collar crime investigations as well as a member of the board of governors for the National Healthcare Anti-Fraud Association (NHCAA), oversees the fraud investigations unit for Regence. Regence fraud investigators uncovered nearly $7.5 million in fraud dollars in 2004.

"We are all hurt by insurance scams," said Johnson. "As health care consumers, we all end up paying the price for fraud. Health insurance fraud perpetrators are basically stealing from consumers who are paying into the insurance system. Whether it's a doctor charging for a procedure that wasn't actually administered or a phony insurance agent selling fraudulent insurance to a senior citizen, the cost of fraud ends up being passed on to consumers."

Johnson is quick to point out that the majority of health professionals are honest and ethical. "Unfortunately, however, the small percentage that makes up the dishonest minority is costing the system billions of dollars every year," he said.

Seniors May be Especially Vulnerable

Senior citizens may be especially vulnerable to health insurance scams this holiday season because of enrollment in the new Medicare Part D prescription benefit.

"Seniors are being solicited by numerous companies to enroll in the new Medicare D program," said Johnson. "As they're looking into all of their options, seniors need to be very conscientious in protecting their health care information, and be careful to enroll only in legitimate programs."

Johnson says that protecting your health insurance information is just as important as protecting your credit card information. He also points out that it's very important to take the time to ask questions and to not feel pressured to make a quick decision. "Medicare D open enrollment doesn't end until May 15, 2006, so there's still plenty of time to look into things," he said. "Ask what company an agent is associated with. Take the time to check out that company or agent to make sure they're registered."

According to the FBI's Web site, seniors are particularly targeted for fraud for several reasons.

  1)  They are more likely to have money, assets and/or good credit, all of

      which are tempting resources for a con-artist to tap into.

  2)  They were raised to generally be trusting and polite, so they are less

      likely to just say "no" or simply hang up the phone.

  3)  They are less likely to report a fraud, possibly fearing that if they

      admit that they were "taken" by a scam that their family will think

      they are no longer able to make their own financial decisions.

  4)  Their testimonies are easy to discount because memory loss is common

      among this group.

  5)  They are among the group of people most concerned about cognitive

      function, virility, physical condition, anti-cancer products, etc.,

      and are more likely to be enticed by scams offering these kinds of

      products.

 

  Take Charge - Protect Yourself

Consumers can reduce their chances of being a victim of health insurance fraud. "The best defense is a good offense," said Johnson. "Consumers can take charge of their own situations by paying attention to the details sometimes overlooked by unsuspecting individuals." Here are some of his tips below:

-- Protect your health insurance information. Never give your health insurance number to telephone or door-to-door solicitors.

-- Read the "fine print." Carefully review the details of any policy or coverage offered before you sign anything, especially sales promotions you receive in the mail. Also, make sure the policy you've signed up for is for the type of insurance that you need. One 93-year-old woman who thought she was buying valuable medical insurance ended up finding out too late that she had purchased maternity insurance instead.

-- Check out insurers and agents. Unscrupulous companies will sometimes use a name that suggests it is associated with a well-known company or government agency such as Medicare or Medicaid. Make sure the insurance company or agent you've signed up with is legitimate. If a company tells you it doesn't have to be licensed or registered with the state, don't do business with that company. You can check out an insurance company or agent by contacting the Oregon Insurance Division in Salem at (503) 947-7980.

-- Watch out for "too good to be true" low rates and terms. Beware of any policy that costs "pennies a day." The low rate could be effective for only a short time - usually 30 days - after which the cost increases dramatically. Also, beware of a health insurance company that will accept almost anyone, even someone with a pre-existing or serious illness. That could indicate you're dealing with a fraudulent company. Be suspicious if an insurance company requires you to pay your premiums in cash, pay for a year's premium in advance, or asks that you sign a blank insurance form.

-- Ask questions. Beware of a company that pressures you to sign up immediately because it's your "last chance." Take your time to make a decision. Do your homework, and get your information in writing. Don't be shy about talking with friends and family or an attorney or even other insurance agencies about the proposed offer or to see if they have heard of the company you're considering.

-- Beware of "free" treatments or products. Lots of community-based organizations offer legitimate free screenings of blood pressure, cholesterol, vision or other basic health indicators. However, sometimes "free" medical treatments are actually just a way for scammers to acquire your name and health insurance information to use in fraudulent billing schemes. Generally, you shouldn't need to give out your health insurance information for a legitimate free screening or treatment.

-- Read your statements carefully. Review your Explanation of Benefits (EOBs) and billing statements and look for any charges that seem wrong to you or any charges for services you don't recall receiving. If you believe you have been billed for a procedure that you did not receive, contact your insurance company ASAP to report the suspicious charges.