How to Report Health Insurance Fraud

Three Methods:Contacting the Insurance CompanyReporting to State or Local BoardsReporting to the Federal Government

Health insurance fraud is a serious problem that impacts everyone. Not only does it decrease your confidence in your healthcare provider and the system as a whole, but it potentially puts your health and private information at risk. If you suspect health insurance fraud, you can report it to your health insurance company, or to state or federal authorities. Who you need to contact may depend on the source of the fraud.[1]

Method 1
Contacting the Insurance Company

  1. Image titled Report Health Insurance Fraud Step 1
    Review your statement to verify accuracy. As soon as you receive a statement from your doctor or an Explanation of Benefits from your insurer, read them carefully to make sure all the entries and amounts are correct.[2][3]
    • Your Explanation of Benefits includes a list of services or supplies that your healthcare provider told your heath insurance company were given to you.
    • If you get a bill or statement from your doctor as well, you should compare the two documents and make sure everything is in order and they both say the same thing.[4]
    • For example, if your EOB states that you received 10 X-rays, but your statement from your doctor says you only received one, this may be evidence of health insurance fraud – but it also may be that an assistant simply typed a zero by accident while he was inputting the information.
    • If you keep a personal log of your doctor visits and what happened at each visit, you also have this to compare against your EOB.[5]
  2. Image titled Report Health Insurance Fraud Step 2
    Ask your doctor to explain entries. If you don't understand something, such as an abbreviation, ask your doctor what it means.
    • Especially if you were unconscious during treatment, there may be entries on your statement that you don't remember.
    • If you have any doubts about whether you actually received a treatment, ask to see your medical records and compare the record to your bill.[6]
  3. Image titled Report Health Insurance Fraud Step 3
    Learn to recognize some common examples of billing issues that might constitute fraud. Certain types of billing entries may seem legitimate but actually are cause for concern.
    • For example, the insurance company may have been billed for each stage of a procedure as though each stage were a separate procedure, rather than being billed a single charge for the procedure as a whole – a practice known as "unbundling" which may be fraudulent.[7]
    • Another type of billing fraud is referred to as "upcoding." This is when the medical professional bills the insurance company for a more costly procedure than what was actually performed.[8]
  4. Image titled Report Health Insurance Fraud Step 4
    Report discrepancies to your insurance company. If you find any differences between your insurer's statement and your medical bill or medical record, let your insurance company know as soon as possible.
    • Often the problem is simply a clerical error that can be easily fixed as long as the insurance company knows about it.
    • However, if you suspect fraud, let your insurance company know and explain the reasons for your suspicions.
  5. Image titled Report Health Insurance Fraud Step 5
    Fill out a complaint form. Your insurance company may have a complaint form available online, or you can call and request an official form.
    • You may be able to remain anonymous, but you must include the names of the person or company suspected of fraud, as well as information about the insured.[9]
  6. Image titled Report Health Insurance Fraud Step 6
    Send a tip through email. If you don't want to fill out an official complaint form or if you don't have enough of the required information to do so, find out if the company has an email where you can submit a tip.
    • For example, if you want to report fraud involving a Blue Cross and Blue Shield company, you can email the BCBS National Anti-Fraud Department at
    • You might use an email instead of a complaint form in situations where you weren't entirely sure about who in a company was committing the acts, or if you had more general suspicions.
  7. Image titled Report Health Insurance Fraud Step 7
    Call the company's hotline. If you wish to remain anonymous, you can call the company's insurance fraud hotline to report your suspicions.
    • For example, if you want to report possible fraud to Blue Cross and Blue Shield, you can call the company's hotline at 1-877-327-BLUE. The hotline is available 24 hours a day, seven days a week.[10]
    • If your insurance company doesn't have a hotline, you can write to an agent or other insurance employee and provide the information you have about the possible fraud.[11]

Method 2
Reporting to State or Local Boards

  1. Image titled Report Health Insurance Fraud Step 8
    Figure out which agency is designated to investigate. Each state has a department of insurance, commerce, or other agency that looks into allegations of health insurance fraud.[12]
    • This agency detects, investigates, and prevents insurance scams and fraudulent activity within your state.
  2. Image titled Report Health Insurance Fraud Step 9
    Contact your state's insurance fraud bureau. Once you determine which agency in your state investigates fraud, find out if they have a form or a hotline for reporting your suspicions anonymously.[13]
    • Insurance fraud agencies typically have phone numbers for citizens to call with tips about scams or suspicious activity.[14]
    • If you thought you bought health insurance, but now the company you bought the insurance from won't answer the phone and your medical bills aren't being paid, you may be the victim of a fraudulent health insurance scheme. These sort of fraudulent activities should be reported directly to your state's insurance fraud bureau.[15]
  3. Image titled Report Health Insurance Fraud Step 10
    Contact your state's medical board or chiropractic board. If you suspect a doctor or medical professional of engaging in fraudulent activities, you can report that to the state board in charge of licensing and discipline of medical professionals.[16]
    • Licensing boards handle problems involving the professional conduct of doctors and other licensed medical professionals. If a doctor is defrauding an insurance company, the board will file charges, conduct a hearing, and impose penalties if the doctor is found guilty.[17]
  4. Image titled Report Health Insurance Fraud Step 11
    Contact your state's hospital association. If your billing discrepancy or other fraud suspicions involve a hospital department or employee, you may be able to report your suspicions to a state association that regulates hospitals.[18]
    • The American Hospital Association website has a list of state, regional, and metropolitan hospital associations in the United States.[19]

Method 3
Reporting to the Federal Government

  1. Image titled Report Health Insurance Fraud Step 12
    Learn to recognize common fraud scams. Many health insurance fraud scams use similar methods or patterns, and you can protect yourself by being wary of those activities.
    • Many health care fraud schemes involve the theft of patient medical information, which the criminals then use to be reimbursed for services or supplies not provided.
    • For example, criminals may offer a free medical screening and use that to obtain your patient information.
    • Another common tactic is to ask you to sign a blank medical form or insurance form. Once a criminal has your signature, he can put whatever he wants on the form and it looks as though you signed off on it, agreed to it, or authorized it.[20]
  2. Image titled Report Health Insurance Fraud Step 13
    Contact your local FBI or HHS-OIG office. The FBI is the primary investigative authority for insurance fraud occurring in both federal and private insurance programs.[21]
    • The FBI has 56 field offices in major metropolitan areas around the country. You can find the field office nearest you using a locator map on the FBI website.[22]
    • You also can use the FBI's online form for tips and public leads. The form does ask for your name, address, phone number, and email address – however, you don't have to include this information if you want to remain anonymous.[23]
  3. Image titled Report Health Insurance Fraud Step 14
    Contact your state's Medicaid fraud office. If you observe suspicious activity involving Medicaid, you should alert state authorities as soon as possible.
    • The Blue Cross Complete Medicaid anti-fraud hotline is 1-855-232-7640.[24]
    • Each state has a particular Medicaid agency with a website and phone number you can use to report fraud. The U.S. Centers for Medicare and Medicaid Services has compiled a chart with the phone numbers and web addresses for each state's agency.[25]
  4. Image titled Report Health Insurance Fraud Step 15
    Report Medicare fraud. Medicare fraud can be reported to the Inspector General using 1-800-HHS-TIPS. This hotline is available 24 hours a day, seven days a week.[26]
    • You also can report Medicare fraud by calling 1-800-MEDICARE, or by sending an online report form to the Office of the Inspector General.[27]
    • Before you report fraud, make sure you have the healthcare provider's name and address, the billing information or other service you're questioning, the date Medicare approved the payment, the date you were provided the service or supplies, the reason you don't think Medicare should have paid, and any other relevant information.
    • You cannot remain anonymous and will have to provide your name and Medicare number.[28]
  5. Image titled Report Health Insurance Fraud Step 16
    Call the Obamacare fraud hotline. The federal government has a hotline available 24 hours a day, seven days a week at 1-800-447-8477 for you to provide any fraudulent activity or identity theft involving insurance policies sold under the Affordable Care Act.[29]

Sources and Citations

Show more... (26)

Article Info

Categories: Health Insurance | Official Writing and Complaints