TRENTON –New Jersey Department of Banking and Insurance Commissioner Ken Kobylowski today urged consumers, particularly senior citizens, to be alert for healthcare insurance fraud, which can include misrepresentations made to consumers during the sales process, submission of claims for services that were either not provided to consumers or misrepresenting the extent of services provided.
The FBI estimates that health care fraud costs the country an estimated $80 billion a year. That cost directly translates into higher insurance premiums for all consumers.
“Consumers can never let down their guard when it comes to healthcare insurance fraud,” said Commissioner Kobylowski. “We cannot afford to ignore fraud’s red flags. Always review a bill issued to your carrier. Even when a medical provider submits it on your behalf, your insurer provides you with an Explanation of Benefits (EOB). Make sure services provided to you are the services described in the bill and the EOB. Report any discrepancies to your insurer immediately.”
The vast majority of medical providers are honest, but recent cases have involved false or inflated charges for services that were not performed. Submitting a false claim form to a health care insurer is a violation of the New Jersey Health Care Claims Fraud Act. Violators are subject to a fine up to $150,000 and a possible sentence of three to five years in jail for each false claim.
Here are tips from Commissioner Kobylowski to avoid health care insurance fraud in claims:
- Review your bill from your health care provider and your EOB from your insurance carrier carefully. Look for charges listed to make sure they were received;
- Watch for erroneous, repetitive listing of procedures for the same service;
- Verify that the doctor requested the services listed;
- Guard your insurance information and make certain that only your providers and carrier have this data;
- Only go to doctors and other medical providers on referrals by people you know and trust. Do not accept money for referrals and watch out for those who may earn cash by sending you to a certain provider. Making referral payments in exchange for patient tests and treatment is illegal.
- Make sure you tell the truth when filing an insurance application and claim. It is illegal to knowingly make an oral or written statement which is false or misleading in order to obtain health insurance.
“If you have a question about something on your carrier’s statement, contact your insurer right away,” said Commissioner Kobylowski. “If you are not certain about something you see in that statement, do not be afraid to question it. Also, if you are not sure about the medical necessity for a prescribed service, you should ask for a second medical opinion.”
The Commissioner offered senior citizens these tips to avoid and combat marketing fraud:
- Be cautious of door-to-door sales people. Do not provide secure information such as Medicare cards or insurance policy information to an unsolicited marketer.
- Verify that your health insurance salesperson and company are licensed. This can be verified through the Department’s website at: https://www16.state.nj.us/DOBI_LicSearch/insSearch.jsp
For inquiries or complaints, consumers can call either (609) 292-7272 or the Department Consumer Hotline (800) 446-7467.
- Check that the plan you have chosen is an approved Medicare plan. All plans are listed at www.medicare.gov or available by calling (800) MEDICARE, (800) 633-4227.
- Do not be fooled if a salesperson claims to be with Medicare or Social Security, even if he or she shows you an official-looking identification card.
- When meeting with salespeople, ask questions about things you do not understand and take notes. Consumers should write down the salesperson’s name, address, phone number, New Jersey license reference number and anything he or she told you. It is recommended that you have a trusted friend or family member with you when you talk to a salesperson.
Anyone who suspects fraud or abuse should contact the New Jersey Department of Banking and Insurance at (800) 446-7467 or file a complaint online at: www.dobi.nj.gov.
To report possible Medicare fraud, consumers can call (877) SMP-4359, (877) 767-4359.