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What Should I Know About Health Insurance Scams?

Avoiding health insurance scams is not easy. For example, thieves may call and use deceptive tactics to catch you off guard. Those calls are designed to obtain health insurance policy information or are part of a healthcare scam. Once a victim's information is compromised, recovery from what happened may be a long-term process. Learning to avoid health insurance scams and recognizing what thieves want makes it harder to steal our health insurance details and personally identifiable information (PII). Education becomes an asset to spotting the red flags of health insurance fraud and healthcare scams.

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Data breaches lead to scams involving healthcare and insurance

The most recent Health and Human Services Office of Inspector General report on medical data breaches shows 725 regulated data breaches in the healthcare field and over 133 million patient records exposed in 2023. Thieves buy and sell patient information from data breaches. Then, use the information to commit healthcare scams.

Healthcare scams have been in the top 10 complaint category, according to the Federal Trade Commission, for more than a few years. Last year, almost 15,000 people filed complaints with the Federal Trade Commission (FTC). The average out-of-pocket loss to a victim is $300, which has doubled in recent years.

Data breaches allow thieves to commit medical scams using stolen health insurance or healthcare details. The fraud may be against a medical provider or pharmacy, and the goal of a criminal is to obtain medical services or gain financially under someone else's name. Attempts to commit a health insurance scam by a thief come in multiple forms. Thieves may also attempt to engage you directly via phone, text, or email. In this scenario, the goal is still to obtain personal health insurance information by using a scam to get it.

Healthcare spam call example

Sometimes a thief will call and advise consumers there is free medical equipment available. People with certain medical conditions who need the equipment offered may decide to share personal information just to get the benefit. However, the call is actually a medical scam to get your health insurance information and bill your medical provider for equipment and future services you didn't receive or need.

Healthcare insurance scam approach

Sometimes, the thief starts with a TV advertisement or healthcare screening event in the community. Thieves can begin a new health insurance scam once you offer up your PII or health insurance policy number. However, this time, your information may be used to commit a healthcare medical scam against a doctor, hospital, or pharmacy. This type of medical scam can leave a victim facing consequences like unpaid medical bills and medical records that don't reflect the victim's health history.

Receiving a bill for medical services, equipment, or care you didn't have is a red flag of health insurance fraud. Victims may not even know their health insurance or medical benefits have been accessed until it's too late. As soon as you receive a fraudulent bill, reach out to the medical provider for more details about your Explanation of Benefits (EOB) to be sure no services on the bill belong to someone else.

Health insurance scam victim impacts

Victim impacts are usually long-term. Cleaning up your medical records to prove you don't have someone else's medical history can get complicated. This list identifies the consequences that victims encounter after a health insurance scam.

  • The health insurance policy information has been compromised
  • Medical records don't match as a thief's records are now mixed in with the victim
  • Medical conditions like cancer or heart attacks are now part of a victim's medical records
  • The victim's personal information including medical history may be repeatedly sold or used by thieves
  • Someone may be denied a life insurance policy due to inaccurate medical history now mixed in with their own.

Steps to take after a health insurance scam

Victims often ask what to do if they suspect a medical scam. What if their health insurance has been used by someone else? Who should they call? Are they required to file a police report? These steps to recovery from a healthcare scam or compromise of health insurance information are part of the process for most victims.

  • Once you confirm medical or personal information is compromised, shut down access to those records right away, including any electronic access.
  • Reach out to impacted parties, like your medical providers, insurance companies, or financial institutions, about information that was shared.
  • You should file a police report about the incident to confirm that you are not involved in any criminal activity now or in the future.
  • File a healthcare fraud report, resources are available at the federal, state, and local levels to obtain information on how to resolve this type of health insurance scam.
  • Assemble a full copy of your current medical history to confirm that it is accurate and that there are no discrepancies.

Health scam prevention includes education. Health insurance scams can reach beyond your medical information. Take any additional recommended steps offered during the report filing to protect all your personal information moving forward.

Federal government intervention in healthcare scams

Federal agencies like the FBI focus on healthcare scams and fraud. It is one of their assigned tasks and a resource for tips on who is likely to commit health insurance scams or fraud. Education is a source of healthcare scam prevention and the FBI focuses its education efforts on areas like medical provider fraud, prescription medication abuse, and recently, COVID-19 healthcare scams. Thieves who intentionally attempt to commit health insurance scams and, eventually, fraud are actively sought out by law enforcement. Over 300 government, public, and private organizations or individuals are participating in healthcare fraud prevention.

State attorney general tips for identifying healthcare scams

Consumers should search for the consumer protection division or insurance fraud division in their home state on how to prevent fraud in healthcare and health insurance. Tips, tools, and resources about spotting health insurance scams, reporting an incident, and even how to report healthcare fraud anonymously can be found.

  • If you receive a medical bill for services you didn't get, don't assume it's a clerical error. Reach out to the medical provider to find out why.
  • You are denied coverage on a life insurance policy due to a specific condition or illness you don't have, exposing your medical records may be compromised.
  • If you receive a call from someone offering "free" medical services or benefits, hang up. Reputable medical providers will not solicit you for "free" services.

Avoiding healthcare scams takes education and awareness. The best asset for anyone is understanding how to spot health insurance scams and remembering to avoid giving personal information to someone by phone, text, or email without first verifying the identity in a different manner than requested. These are the tools that reduce a thief's success.


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