We Asked Prosecutors if US Health Insurance Companies Care About Fraud. They Laughed at Us.
To protect their networks and bottom lines, health insurers don’t aggressively pursue widespread fraud, making it easy for scammers. Then they pass the costs off to you.
 
Like most of us, William Murphy dreads calling health insurance companies. They route him onto a rollercoaster of irrelevant voice menus, and when he finally reaches a human, it’s a customer service rep who has no idea what he’s talking about. Then it can take days to hear back, if anyone responds at all.
 
The thing is, Murphy isn’t a disgruntled patient. He prosecutes medical fraud cases for the Alameda County District Attorney’s Office in Oakland, California. And when he calls insurers, he’s in pursuit of criminals stealing from them and their clients. But, he said, they typically respond with something akin to a shrug. “There’s no sense of urgency, even though this is their company that’s getting ripped off.”
 
It’s not just Murphy. I called health care fraud prosecutors across California to ask what insurers were doing to help bring cases against those plundering health care dollars. More than one simply burst out laughing. “Not much,” one prosecutor said.
 
It seems counterintuitive. Escalating health care costs are one of the greatest financial concerns in the United States. And an estimated 10% of those costs are likely eaten up by fraud, experts say. Yet private health insurers, who preside over some $1.2 trillion in spending each year, exhibit a puzzling lack of ambition when it comes to bringing fraudsters to justice.
 
Like much of what happens behind the scenes in the health insurance industry, the insurers’ tepid response to fraud typically goes unexamined. But this year, I dove into the crazy tale of a Texas personal trainer who didn’t have a medical license but was easily able to claim he was a doctor and bill some of the nation’s most prominent health insurers for four years — walking away with $4 million. David Williams, who was also a convicted felon, discovered stunning weaknesses in the system: that when he applied for a National Provider Identifier, the number required to bill health insurance plans, no one would verify whether he was a doctor; and that when he billed insurers as an out-of-network “doctor,” they wouldn’t check either and would keep paying him even long after they learned of his fraud. He was later convicted of health care fraud and is now in federal prison.
Williams’ scam raised the eyebrows of even my most jaded health care sources. It prompted a half-dozen Democratic senators to write to the federal agency that administers the NPIs and ask what it was doing to plug the “loopholes.”
 
But it also got me thinking: As journalists, we are peppered with press releases touting the fraud enforcement successes in Medicare and Medicaid, the government health plans. The federal Department of Justice and state Medicaid Fraud Control Units file thousands of criminal and civil cases a year (and still are accused of not being as aggressive as they could be). Clearly, their goal is to let folks know they will be prosecuted.
 
But we rarely hear about the fraud enforcement efforts of private health insurers.
 
These companies manage the plans of about 150 million Americans who get their health benefits through their employers. They’re sitting on a massive trove of claims data that can help identify scammers, and problems are routinely flagged by their members. And experts, including investigators who once worked for the insurers, tell me there’s rampant fraud against the private plans.
 
The bottom line is significant: If a con artist, or a corrupt medical professional, makes off with health care dollars, those losses are not necessarily the insurers’.
 
They will be passed on to people covered by the plans in the form of higher monthly premiums and out-of-pocket costs as well as reduced benefits.
 
So, what’s up? Continue Reading...
 
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    Insurance Regulator slaps Rs 1.11 crore penalty on Policybazaar
    Finding it guilty on multiple counts, Insurance Regulatory and Development Authority of India (IRDAI) has slapped a penalty of Rs 1.11 crore on insurance web aggregator Policybazaar and has also issued a stern warning against violation of rules in future.
     
    The regulator has directed the firm to deposit the penalty within 15 days from the receipt of the order.
     
    "lf the web aggregator feels aggrieved by the above decision in this order, an appeal may be preferred to the Securities Appellate Tribunal as per Section 110 of the lnsurance Act, 1938," the IRDAI order stated.
     
    The IRDAI in its order said that Policybazaar had failed in complying with the Regulations on Insurance Web Aggregator Regulations issued in 2013 and 2017 which had been created to protect the interest of the policyholders and regulate the business of web aggregation.
     
    "This is evident from the penalties and the warning issued for violations of Insurance Web Aggregator Regulations," it said.
     
    Policybazaar Insurance Web Aggregator Pvt Ltd is the largest web aggregator in the country. Being a pioneer in online distribution space, it has changed the way insurance was sold and has created a name for itself.
     
    Disclaimer: Information, facts or opinions expressed in this news article are presented as sourced from IANS and do not reflect views of Moneylife and hence Moneylife is not responsible or liable for the same. As a source and news provider, IANS is responsible for accuracy, completeness, suitability and validity of any information in this article.
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    COMMENTS

    Anand

    3 weeks ago

    Good. Along with this there should also investigation on how they sell contact numbers of end users and displays wrong messages to get agreement from end users. Not sure how to file or report against this behaviour

    The Extortion Economy: How Insurance Companies Are Fueling a Rise in Ransomware Attacks
    Even when public agencies and companies hit by ransomware could recover their files on their own, insurers prefer to pay the ransom. Why? The attacks are good for business.
     
    On June 24, the mayor and council of Lake City, Florida, gathered in an emergency session to decide how to resolve a ransomware attack that had locked the city’s computer files for the preceding fortnight. Following the Pledge of Allegiance, Mayor Stephen Witt led an invocation. “Our heavenly father,” Witt said, “we ask for your guidance today, that we do what’s best for our city and our community.”
     
    Witt and the council members also sought guidance from City Manager Joseph Helfenberger. He recommended that the city allow its cyber insurer, Beazley, an underwriter at Lloyd’s of London, to pay the ransom of 42 bitcoin, then worth about $460,000. Lake City, which was covered for ransomware under its cyber-insurance policy, would only be responsible for a $10,000 deductible. In exchange for the ransom, the hacker would provide a key to unlock the files.
     
    “If this process works, it would save the city substantially in both time and money,” Helfenberger told them.
     
    Without asking questions or deliberating, the mayor and the council unanimously approved paying the ransom. The six-figure payment, one of several that U.S. cities have handed over to hackers in recent months to retrieve files, made national headlines.
     
    Left unmentioned in Helfenberger’s briefing was that the city’s IT staff, together with an outside vendor, had been pursuing an alternative approach. Since the attack, they had been attempting to recover backup files that were deleted during the incident. On Beazley’s recommendation, the city chose to pay the ransom because the cost of a prolonged recovery from backups would have exceeded its $1 million coverage limit, and because it wanted to resume normal services as quickly as possible.
     
    “Our insurance company made [the decision] for us,” city spokesman Michael Lee, a sergeant in the Lake City Police Department, said. “At the end of the day, it really boils down to a business decision on the insurance side of things: them looking at how much is it going to cost to fix it ourselves and how much is it going to cost to pay the ransom.”
     
    The mayor, Witt, said in an interview that he was aware of the efforts to recover backup files but preferred to have the insurer pay the ransom because it was less expensive for the city. “We pay a $10,000 deductible, and we get back to business, hopefully,” he said. “Or we go, ‘No, we’re not going to do that,’ then we spend money we don’t have to just get back up and running. And so to me, it wasn’t a pleasant decision, but it was the only decision.”
     
    Ransomware is proliferating across America, disabling computer systems of corporations, city governments, schools and police departments. This month, attackers seeking millions of dollars encrypted the files of 22 Texas municipalities.
     
    Overlooked in the ransomware spree is the role of an industry that is both fueling and benefiting from it: insurance. In recent years, cyber insurance sold by domestic and foreign companies has grown into an estimated $7 billion to $8 billion-a-year market in the U.S. alone, according to Fred Eslami, an associate director at AM Best, a credit rating agency that focuses on the insurance industry. While insurers do not release information about ransom payments, ProPublica has found that they often accommodate attackers’ demands, even when alternatives such as saved backup files may be available.
     
    The FBI and security researchers say paying ransoms contributes to the profitability and spread of cybercrime and in some cases may ultimately be funding terrorist regimes. But for insurers, it makes financial sense, industry insiders said. It holds down claim costs by avoiding Continue Reading… 
     
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