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Health Insurance Fraud

A doctor charges $200 for an office visit, but only $80 is covered by the insurer leaving the patient to pay the difference. Investigators allege that health insurance companies are forcing patients to pay more than they should when using doctors and hospitals outside their insurer's networks.

Investigators claim an industrywide scheme is deceiving and defrauding insured consumers, charging hundreds of millions of dollars in extra expenses.

It is customary for people who want to use a doctor outside the insurer's network to pay an additional 20 percent of "reasonable and customary" charges. However, investigators suspect the insurers of systematically underestimating these charges, and therefore forcing their clients to pay a bigger portion of their medical bills than thay are supposed to.

The companies under suspicion include UnitedHealth Group, Aetna, Cigna, Empire Blue Cross and Blue Shield.

Ingenix, a company used by health insurers to calaculate "reasonable and customary" rates, is also under suspicion for systematically reducing the amount of money patients should have been reimbursed. Ingenix is owned by UnitedHealth.

Investigators claim that doctors typically charge $200 for an office visit. Ingenix however, calculates the rate at only $77. The insurer would typically be responsible for paying 80% of the $77 -- $62 -- leaving the patient to pay the remaining $138.

The insurers are accused of manipulating information to arrive at artificially low rates. It is a blatant conflict of interest for insurers to set the rate data when they obviously stand to gain millions of dollars by setting artificially low rates.

Health Insurance Fraud Legal Help

If you believe your health insurer has forced you to pay too much to use a doctor or hospital outside your insurer's network, please click the link below to send your complaint to a lawyer to evaluate your claim at no cost or obligation.
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READER COMMENTS

Posted by
Ohio
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Member of a class who is exposed to repeated fraudulent billing and recently threatened by a collection agency for the $25 difference even after multiple similar prior claims have been adjusted by the insurance company and/or the urgent care center.

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