October 29, 2009

Health Insurance Fraud: An Overview

Written by Sara Rosenbaum, Nancy Lopez, Scott Stifler, all from the School of Public Health & Health Services, George Washington University., they write that in 2007, the U.S. spent nearly $2.3 trillion on health care and public and private insurers processed more than 4 billion health insurance claims. The National Health Care Anti- Fraud Association (NHCAA) has estimated that, conservatively, 3% of all health care spending is lost to health care fraud. Other estimates by government and law enforcement agencies place fraud-related losses as high as 10% of annual health care spending. What is absolutely clear from virtually every reliable source on the subject is that health care fraud is a systemic problem affecting public and private insurers alike, in the individual market, the employer-sponsored group market, and public programs. Because Medicare and Medicaid are government-sponsored and thus are required to report on fraud, the problem is perhaps better known, but combating fraud is a challenge that faces both public and private insurers. The failure to systematically and routinely measure the scope of fraud is characteristic of the insurance industry as a whole. Numerous government agencies have reported that no segment of the health care delivery system is immune from fraud and that instance of fraud and abuse can be found involving all segments of the health care industry.