Nebraska Department of Insurance

NEBRASKA DEPARTMENT OF INSURANCE INSURANCE FRAUD PREVENTION DIVISION 941 O Street, Suite 400 Lincoln, NE 68508-3639

Medical Provider Fraud Hints

It is important to remember that the hints listed below are merely possible "red flags" that there may be some evidence consistent with an insurance fraud scheme.  Any one or two of these by themselves, may not raise your suspicion; however, when you have several of these hints present or a pattern begins to emerge, you should investigate further or forward your suspicion to the Insurance Fraud Prevention Division.

1. The insured/claimant has extensive knowledge of medical terms and procedures, billing codes, and insurance claims handling procedures.
2. Different type styles used in different areas of medical bill listing services, treatments, diagnoses, procedures, and charges.
3. Medical treatments are unrelated to, or inconsistent with diagnosis.
4. Medical bills show consecutive days of treatment.
5. Medical providers treat family members who were not involved in the accident, particularly in mental health claims.
6. Medical bills show treatment on days immediately prior to policy termination date.
7. Referring doctor and provider of services share same address.
8. Referring doctor and provider of services use the same tax identification number (TIN) for billing.
9. Referring doctor and medical provider belong to the same professional corporation.
10. Number of prescriptions, or quantity per prescription, is unusually large.
11. Many prescriptions for scheduled controlled substances identified in the Physician's Desk Reference (PDR).
12. Drugs prescribed are not directly related to the injury or illness.
13. Location of pharmacy is different geographically from work/home.
14. Prescriptions phoned into the pharmacy, but the doctor has no record of calling them in.
15. Pharmacy dispensed generic drugs while brand name drugs were billed.
16. Dental services rendered for Temporomandibular Joint Syndrome (TMJ) after an automobile accident, even though condition preexists.
17. TMJ claim is not supported by medical records or evidence.
18. Chiropractic care received for TMJ although no other chiropractic care is noted.
19. Dental bills submitted which incorrectly show treatment in two different calendar years.  This is to assure that coverage is not maximized in one year.
20. Dental bills are padded or inflated to reimburse for co-payments or deductible.
21. Dental bills submitted for services not rendered, such as billing for crown and bridge work where root canal was actually performed.
22. Medical provider submits identical claims for the same patient in different calendar years.
23. Several medical bills submitted on different dates, each showing same dates of service or overlapping dates of service.
24. Dates of service in doctor's notes do not match dates of service on the bill.
25. Office visits are not itemized by date and type of service.
26. Medical bills list duplicate procedures or unbundled procedures to maximize payment.
27. Medical services billed but not rendered.
28. Medical provider has never seen the patient on the dates indicated on the bill or has no knowledge of the patient.
29. Medical bills received from multiple medical providers who are not specialists.
30. Medical bills addressed to claimant's attorney.
31. Photocopies are submitted rather than originals.
32. Medical provider administers unnecessary treatment or medical procedures are incidental to the actual injury or illness.
33. The rental fee for Durable Medical Equipment (DME) exceeds the actual cost of the item.
34. DME company upgrades the item on the bill but actually dispenses a lower quality item such as billing for an electric wheel chair while actually providing a standard wheel chair.
35. Claimant submits bills for more TENS units or other equipment than was actually received from the DME company.