Medical provider fraud pertains to deceitful activities such as submission of falsified medical bills, billing for services not rendered, magnifying the severity of injuries and administering unnecessary tests. This type of fraud is typically perpetrated by healthcare professionals, including doctors, physical therapists, chiropractors and ancillary companies, and it can lead to substantial financial loss and other detrimental effects. Here are some important points to consider to help you fight and lower the impact of fraud.
Who is impacted by medical provider fraud?
Medical provider fraud can affect everyone – from insureds and claimants to workers and businesses. Some medical practices are controlled by non-practitioners who focus more on prioritizing profits than ensuring patient care, and patients may be subjected to unnecessary medical treatment, procedures, tests or medications. For example, from 2010 to 2013, doctors in California were paid illegal kickbacks for patient referrals, which led to unnecessary spinal surgeries. As a result, some patients suffered serious complications and long-term health problems.
Insurance companies are also impacted, as medical provider fraud influences healthcare premium rates by increasing the overall costs to corporations, small businesses and individual consumers obtaining coverage.
How does CNA respond?
CNA is positioned to leverage all available resources to proactively detect emerging schemes and thoroughly investigate questionable activity. We employ organizational defenses to limit payments from being made to fraudulent businesses. If it’s later determined this occurred, we leverage our civil affirmation litigation strategy to recover payments and work to remove fraudulent providers from our payment process. We also work with law enforcement and prosecutors to ensure appropriate restitution is recovered and ultimately credited back to the proper claim files.
As medical provider fraud evolves, CNA continues to build on our anti-fraud investment and our commitment to being industry leaders in this arena.
Check out the links below to learn more.
Special Investigations Unit
If you have questions or would like to learn more, please contact Steven Piper, CNA's Global Head of Special Investigations, at Steven.Piper@cna.com.
One or more of the CNA companies provide the products and/or services described. The information is intended to present a general overview for illustrative purposes only. It is not intended to substitute for the guidance of retained legal or other professional advisors or to constitute a binding contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states. Copyright © 2023 CNA. All rights reserved.