State Regulators Look to Put a Dent in Fraud Cases, Help Consumers

As some individuals look for ways to skirt the system, insurance regulators in some states are going after them with more fervor these days, meaning more protections for consumers.

At a recent gathering of panelists at the National Summit on Health Care Fraud in Washington, D.C., four members of the National Association of Insurance Commissioners (NAIC) discussed how their respective states were fighting fraud when it comes to Medicare, Medicaid and private insurance markets.

Kansas Insurance Commissioner Sandy Praeger, who oversees the NAIC's Health Insurance and Managed Care Committee, notes that, "Protecting consumer information from medical identity theft will help both consumers and the industry. We must prevent payments by insurance carriers or the government for fraudulent services. Billing for services not performed and falsely creating a patient's health history are a costly source of waste and abuse.'

Jane Cline, NAIC President and West Virginia Insurance Commissioner, added, "Legislative reform should address the need for plan administrators or providers to have an active antifraud plan.'

As it stands now, the NAIC is drafting a guideline for antifraud plans that will help companies without an antifraud plan along with states that have yet to adopt antifraud plan language in their regulation or code.

Illinois Director of Insurance Michael McRaith noted the importance of state insurance departments when it comes to tackling fraud.

"As the first line of defense against health insurance fraud, regulators coordinate with law enforcement to process complaint referrals, and investigate and prosecute allegations of insurance fraud. Providers who intentionally bill for services not medically necessary or bill for services not provided should be vigorously prosecuted.'

Stepped up prosecution will go a long way in assisting consumers in bringing down the costs of health insurance that we all pay.

In turn, it is important for consumers to practice vigilance when shopping for health insurance or any other kind of coverage.

If something sounds too good to be true, it probably is.