Who Are The Victims Of Insurance Fraud?

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Sandie Baillargeon Posted on July 4th, 2018

Blog by Dental Office Consulting Services Inc.

Victim #1 – The Patient – (who is victimized twice)

The patient is victimized by his/her insurance benefits sometimes being maxed out. If a patient realizes that something is wrong with their insurance benefit entitlement and it is the result of what is happening at your office, they will blame you, because you are the dentist. The victim will not know, or care, that you have had a dishonest employee working for you who did these acts without your knowledge or consent.

Over-utilization of insurance benefits will result in employers not purchasing dental benefits for their employees. Dental insurance is the most costly component of a group insurance benefits plan. If the costs for the premiums rise due to the inflated utilization rate that was created by false claims, employers are likely to drop dental benefits from their employee benefits packages. When employers are faced with economic stresses, paying premiums for dental benefits become too cost prohibitive to sustain. The patient is now victimized a second time because they lose their employer paid benefit.

Victim #2 – The Doctor – Guilty Until Proven Innocent

If insurance companies launch an investigation and the doctor is aware of some problems that exist, but does not act on them, he/she is considered the prime suspect. In other words, the insurance company will assume that the doctor is responsible and his hands are dirty. Some insurance companies can, and will, deny any future claims that come from your office. You are considered guilty until proven innocent and even then, you are still guilty.

The doctor will also be expected to pay the insurance company back all payments that were received from fraudulent claims. That can become an administrative nightmare to sort out which claims were legitimate and which were not , costing the doctor both time and money.

In some cases the doctor may have his/her license suspended or revoked if they knowingly allowed insurance fraud to occur and did nothing about it after it was discovered. You are responsible for the actions of your employees because it is assume that they work under your direction.

Victims #3, 4, 5… – Collateral Damage

If the doctor and or hygienist loses their licenses, who will treat the patients? Also, the jobs for the remaining staff are in jeopardy making them victims as well. A lot of honest, hard-working people can become the collateral damage of the perpetrator’s misguided actions and the doctor’s career can be ruined.

What should you do if you suspect or detect fraudulent activity? The most important advice that you can receive is get professional help – don’t try to do it all yourself.

Author: Sandie Baillargeon