To protect their networks and bottom lines, health insurers don’t aggressively pursue widespread fraud, making it easy for scammers. Then they pass the costs off to you.
Like most of us, William Murphy dreads calling health insurance companies. They route him onto a rollercoaster of irrelevant voice menus, and when he finally reaches a human, it’s a customer service rep who has no idea what he’s talking about. Then it can take days to hear back, if anyone responds at all.
The thing is, Murphy isn’t a disgruntled patient. He prosecutes medical fraud cases for the Alameda County District Attorney’s Office in Oakland, California. And when he calls insurers, he’s in pursuit of criminals stealing from them and their clients. But, he said, they typically respond with something akin to a shrug. “There’s no sense of urgency, even though this is their company that’s getting ripped off.”
It’s not just Murphy. I called health care fraud prosecutors across California to ask what insurers were doing to help bring cases against those plundering health care dollars. More than one simply burst out laughing. “Not much,” one prosecutor said.
Source: Read more at ProPublica
Exactly. A couple of years ago, my PM&R (pain) doctor prescribed a creme for pain instead of opiods. He said don’t worry , it will be shipped to you. When I got the creme there was no copay or bill attached. When I check my insurance benefits statements, the insurance had been charged $2000 for one round of this “compounded RX” .
I called BCBS of TX to complain and they turfed me to Express Scripts, our PBM, who basically acted dumb and didn’t even know what to do about it. It was obviously a kick-back scam, who knows how many patients were prescribed the compounded creme from CA.
Then they sent me refills I didn’t ask for. I couldn’t return it and the PBM paid our close to $8000. Nothing was ever done about it.