10 Warning Signs of Medical Fraud and How Healthcare Providers in Texas Can Protect Themselves

Health insurance is a crucial lifeline, designed to provide access to necessary treatments, preventive services, and emergency care. Unfortunately, it has also become a lucrative target for scammers, especially in the healthcare industry. For healthcare providers and business owners in Texas, staying vigilant against medical fraud is essential.

In February of this year, Change Healthcare, a major player in the healthcare industry, fell victim to a cyber-attack that impacted thousands of healthcare providers, insurers, and policyholders nationwide. Alarmingly, reports from this incident suggest that around 50% of all U.S. medical claims could be at risk. To put that into perspective, if you’re in a waiting room with nine other people, there’s a good chance that five of you could fall victim to medical identity theft within the year. The aftermath of such fraud can be devastating, affecting countless individuals’ access to healthcare. Once your medical information is exposed online, identity thieves can use it to file false claims, buy expensive prescriptions, and more—all conveniently billed to your account.

What’s even more concerning is how some people are discovering they’ve been affected. Some are facing tax or mortgage fraud, while others, expecting to schedule a necessary procedure, receive a rejection letter from their insurance provider. The reason? The insurer claims they’ve exhausted their benefits due to multiple other procedures this year. But here’s the kicker: they didn’t undergo any other procedures. Someone else stole their medical ID and used it for their own treatment.

This issue extends beyond individuals to affect healthcare providers and organizations as well. Manipulative entities can exploit your medical information for fraudulent billing schemes. They submit false claims for services you never requested, received, or even knew about, then they collect their payday, leaving you or your organization stuck with the bill. In July, 193 defendants, including 76 doctors, nurse practitioners, and other licensed medical professionals, were charged for their alleged involvement in various healthcare fraud schemes that resulted in $2.75 billion in false billings to federal programs. Medical fraud is a real and pressing issue!

How to Recognize Medical Fraud: 10 Warning Signs for Healthcare Providers and Patients

Here are 10 signs that your medical ID—or that of your patients—may have been stolen and is currently being exploited by cybercriminals:

1. Unexpected Medical Bills: Receiving bills for medical services you didn’t receive is a major red flag.
2. Collection Notices: Being contacted by debt collectors for unpaid medical bills that aren’t yours.
3. Errors in Medical Records: Discovering inaccuracies in medical records, such as treatments you never had, incorrect diagnoses, or unfamiliar medical histories.
4. Insurance Issues: Health insurance claims are denied because benefits have been maxed out, or you’re informed you’ve reached your coverage limit, despite not using those services.
5. Notifications from Insurance Providers: Receiving alerts from your health insurance provider about claims or services you don’t recognize.
6. Unknown Accounts: Discovering new health insurance accounts or medical records under your name that you didn’t create.
7. Discrepancies in Explanation of Benefits (EOB): EOB statements from your insurer list medical services you didn’t receive.
8. Denial of Insurance: Having difficulty obtaining life or health insurance because of medical conditions you don’t have listed in your records.
9. Calls from Medical Providers: Receiving calls from doctors or medical facilities about appointments or follow-ups for treatments you never had.
10. Unfamiliar Prescriptions: Notices about prescriptions being filled in your name that you did not authorize or receive.

Protecting Your Healthcare Business from Medical ID Fraud

Healthcare providers and business owners in Texas must take proactive steps to protect themselves and their patients from medical ID fraud. Here’s how:

• Check for Healthcare Breaches: Regularly use a searchable database, like this one, to determine if your healthcare organization’s information has been compromised.
• Secure Your Records: Store physical copies of medical records in a safe or lockbox to prevent unauthorized access. If your healthcare organization’s system is compromised, having secure backups can be a lifesaver.
• Shred Documents: Always shred documents containing personal information before disposal.
• Monitor Medical Records: Regularly request and review medical records for unfamiliar treatments, diagnoses, or other discrepancies.
• Review Insurance Bills: Carefully examine Explanation of Benefits (EOB) statements for any services you did not receive. Contact your insurer immediately if you see any charges or services that you don’t recognize. Afterward, report any billing errors to the credit bureaus at IdentityTheft.gov.
• Dispose of Prescription Labels: Remove labels from empty prescription bottles before discarding them to prevent identity theft.
• Monitor Your Credit: Use AnnualCreditReport.com to get three free reports a year to monitor any suspicious activity.

Healthcare will always be a vital industry, but it will also always be a target for hackers. Attacks on hospitals, doctors’ offices, and other medical facilities will continue. It’s crucial for healthcare providers in Texas to take proactive measures to protect themselves.