The Problem Of Insurance Fraud Essay

1475 words - 6 pages

Fraud is common among many aspects of society, one of the most prevalent types of fraud is

insurance fraud. The fraud occurs on both ends from the insurer, to the people who use insurance

including the physicians and the patients. A frauds usually cost Americans about thirty billion each

year, which is a high cost for the amount of the money that those involved in the fraud often get from

insurance (O'Rourke, 2003). For example, In 1995 alone one trillion were spent on health care, and

10-15 percent of that payment was comprised of health insurance fraud (Skeen, 2003). What is more,

insurance fraud is often placed in two categories, hard and soft fraud, where hard fraud is the willful

of a person to commit the fraud and the soft fraud is a more indirect form of fraud (Tennyson, 2008).

Hard fraud cases are more likely to be considered criminal fraud, because sufficient evidence must be

provided that the person willfully committed the acts (Tennyson, 2008). These frauds are often more

difficult to discover because there is a level of trust that's involved, however when it becomes evident

that a fraud may have occurred, it is my job as a fraud investigator to get to the bottom of it in order to

resolve whether a fraud was committed or not and from whom. The crimes are often committed during

economically hard times, which means that in many cases, the people involved in the fraud are just as

affected by the economic state of the nation as the people who are affected by the fraud (Scafidi, 2010).

The people are less likely to believe that they have anything to lose, and are more likely to risk losing

assets and their integrity for the money that they envision receiving in the short-term (Scafidi,2010).

Investigators are often required to use medical records, claims that are filed, and other relevant

information in order to provide sufficient information that would substantiate frauds committed by

patients or physicians (Scafidi, 2010).

There was a particular case that stood out, which involved the willful act of a physician to

commit hard fraud against his patients. In this case, a health insurance company, Instant Mutual, called

stating that one of their clients were complaining of their bill, stating that it was unreasonably high. The

client had been sick for a while, and stated that she had been visiting a gastroenterologist for the

treatment for Irritable Bowel Syndrome (IBS). The client had been referred to a gastroenterologist, Dr.

John Spirolact , by her primary care physician, Dr. Codonea. Dr. Spirolact had practiced for about

twenty-five years, and was known for his treatment of diseases like IBS, Crohn's disease, and

ulcerative colitis. The insurance company stated upon speaking with the doctor a few days later, he

stated that he was treating her for symptoms of Crohn's disease, which has similar symptoms to IBS,

but is far more...

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