Health Insurance Fraud

Health Insurance Fraud


Health Insurance fraud

Health insurance fraud is the purposeful act of deceiving, concealing, or misrepresenting the health care benefits being paid to an individual or group.

Health insurance fraud may be defined in the health insurance context as any behavior designed to solicit money to which a person or group is not entitled. Health Insurance Fraud perpetrators include insurance brokers, unscrupulous doctors, chiropractors, allied health professionals, medical institutions, and patients.

In response to the increased amount of health insurance fraud in the United States, Congress, through the Health Insurance Portability and Accountability Act of 1996 (HIPAA), has specifically established health care fraud as a federal criminal offense with punishment of up to ten years of prison in addition to significant financial penalties.


Health insurance fraud cost estimates

The FBI's Health Care Fraud Unit oversees investigations targeting individuals and/or organizations who are defrauding public and private health care systems. Areas investigated under Health Care Fraud include: billing for services not rendered, billing for a higher reimbursable service than performed (upcoding), performing unnecessary services, kickbacks, unbundling of tests and services to generate higher fees, durable medical equipment fraud, pharmaceutical drug diversion, outpatient surgery fraud, and Internet pharmacy sales.

The cost of health care fraud and abuse in both the public and private sectors, is estimated between 3 and 10 percent of total health care expenditures. Total health care spending to is estimated to exceed $3.3 trillion in 2012.

It is estimated that Health Care Fraud will cost the American Health Care system between $99 Billion and $330 Billion in the year 2012.


Fraud Resources

Resources to to help you learn more about fraud protection and fraud an to assist investigators in their efforts to combat fraudulent activity.


fraud jobs

A Fraud Investigator conducts civil and criminal investigations. The field of fraud investigations is a dynamic and challenging career choice.