Articles Tagged with insurance fraud

hush-naidoo-382152-copy-300x200Insurance fraud can take place across multiple industries, from automobile insurance to medical insurance to property insurance. In most cases, the victim does not even know that he or she has been defrauded. By making yourself aware of common insurance fraud schemes in California, you can better equip yourself to identify insurance fraud when it occurs and help stop insurance fraud in California. If you believe you have witnessed an incident of insurance fraud, call Brod Law Firm at (800) 427-7020 today to speak with an experienced qui tam attorney and learn how you can help.

What is Insurance Fraud?

The California Penal Code defines insurance fraud as the willful injury, destruction, or disposition of any property that is insured against loss or damage. Consumers and businesses alike can be guilty of insurance fraud. While a consumer might be found committing insurance fraud by submitting a claim to his or her insurance company based on false injuries, a business might be found committing insurance fraud by inflating the cost of their services or billing for services that were never performed. While insurance fraud can take place in just about any industry, the most common industries in which insurance fraud is seen are the automobile, healthcare, workers’ compensation, property insurance, and life insurance industries.

daan-stevens-282446-copy-300x191California lawmakers are concerned with health care providers who may be taking advantage of patients by unnecessarily enrolling them into commercial health care plans in order to maximize the provider’s reimbursement rates. Lawmakers believe some providers are encouraging sick individuals to enroll in commercial health care plans, which the providers then pay the premiums for in addition to providing the patient medical services. The providers financially benefit from the patients utilizing these health plans by receiving reimbursements for their services.

While providers claim their third-party premium payments are intended to help people get the medical care they need, lawmakers are concerned it is a way for providers to get greater reimbursements than the individual’s Medicare or Medicaid coverage would provide. While the scheme may not rise to the level of health care fraud, legislators worry that it takes advantage of the system and patients.

Lawmakers also worry about the providers ceasing premium payments. Many providers choose to end payments at a certain point, causing sick patients to lose their coverage. A recently introduced bill would create safeguards against such occurrences.

jimi-filipovski-189724-copy-300x176There are currently two False Claims Act (FCA) qui tam cases against United Health Group (UHG) pending in the Central District of California. The cases are: U.S. ex rel. Benjamin Poehling v. UnitedHealth Group, Inc. and U.S. ex rel. Swoben v. Secure Horizons, et al. The cases were brought by James Swoben, who was previously an employee of Senior Care Action Network Health Plan and a consultant within the risk adjustment industry, and Benjamin Poehling, who was the former finance director of a UHG group that managed the insurer’s Medicare Advantage Plans.

The Qui Tam Cases Against UHG

On May 2, the U.S. intervened in the Swoben False Claims Act suit against UHG based on the allegations the insurer overcharged Medicare Advantage and prescription drug programs. In the DOJ’s complaint, it alleges the insurer knowingly ignored patients’ medical conditions to increase payments it received from Medicare and funded chart reviews to increase the risk adjustment payments it reviewed. However, any information the reviews uncovered regarding misdiagnoses were disregarded to avoid repaying Medicare.