What is Health Insurance Fraud?

Tricia Christensen
Tricia Christensen

Fraudulent behavior may loosely be defined in the health insurance context as any behavior designed to solicit money to which a person or group is not entitled. There are so many kinds of health insurance fraud it would be difficult to list them all. This is especially the case because fraud involving health insurance is perpetuated by a variety of sources, including health insurance companies, insurance brokers, unscrupulous doctors, chiropractors, allied health professionals, medical institutions, and patients.

Health insurance.
Health insurance.

Some examples of institutional or health professional led health insurance fraud include the falsification of information on forms. This is not always meant for the personal benefit of the health professional or the institution. Sometimes a doctor will omit information on forms that would lead a patient to not get treatment because of a pre-existing condition, or a hospital will change the time of admission slightly so a patient isn’t charged for a whole day. Though these actions are well meaning, they are nevertheless fraudulent because they do not make an accurate report to the patient’s insurer.

A health insurance claim form.
A health insurance claim form.

Intentional health insurance fraud does not even have this excuse of trying to help a patient. Instead, doctors, allied health care workers or hospitals may file false claims, claim treatments for patients that never occurred, fill prescriptions under patients’ names and then sell them on the black market, diagnose diseases that do not exist, and order unnecessary testing. Occasionally, a medical worker works in collusion with a personal injury attorney to falsify medical reports, in which case more than one type of insurance fraud may be perpetuated.

Health insurance companies or brokers may also commit various forms of health insurance fraud. The biggest of these is not paying on legitimate claims. Some companies may intentionally deny payment in the hopes that claimants will not protest the treatment. They could also deny based on reasons that are unfounded or illegal, but can reverse their decisions if people bother to investigate the denial. Routine misrepresentations of coverage may fall under the health insurance fraud umbrella too. When insurance representatives do not truthfully disclose information on what is covered, which can happen, they may be defrauding their customers by avoidance of payment, or by discouraging customers to get treatments they need, which truly are covered by their insurance.

Alternately, some “health insurance companies” or “brokers” are not truly legitimate and are instead scammers looking to make a quick buck on people who are desperate for health insurance. They have no intention of paying claims and merely want to collect their money. An additional type of health insurance fraud is making false claims about what is being sold. For instance, health discount plans are not insurance. When they are represented as insurance, this may be a fraudulent act. Selling insurance in a state in which a company is not licensed to operate is fraud too.

Lastly, patients can commit health insurance fraud in a variety of contexts. They could make false claims about illnesses for any number of reasons. If an insurance company demands any form of physical, and a patient doesn’t provide accurate information, this could be viewed as fraudulent and might void any coverage. Also, patients who are willing participants in the fraudulent acts of physicians or facilities that misreport information are a party to fraud and could be prosecuted.

Tricia Christensen
Tricia Christensen

Tricia has a Literature degree from Sonoma State University and has been a frequent wiseGEEK contributor for many years. She is especially passionate about reading and writing, although her other interests include medicine, art, film, history, politics, ethics, and religion. Tricia lives in Northern California and is currently working on her first novel.

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Discussion Comments


I had a slip and fall case at a store in Florida. I went to a lawyer and he told me to go to this doctor's office, then after three years, he dropped my case. I signed a letter of protection with him for the doctor's office and now the doctor wants the money from me from day one when I went to his office. He was billing my Tricare, then he stopped and Tricare won't pay. They said he waited too late to file. He didn't even send them a bill first, and now a creditor is taking me to court for $13,000.

The lawyer's paper says treatment was over in 2010, but he still saw me until 2012. Now I have the toughest judge in America. I also have statements from Tricare saying I owe less than the amount or none at all.

Everything is in my husband's name: house cars and accounts, and I have no job going on seven years with three kids so please help. Can anyone help me pro bono? What do I do? How do I defend myself in court and will they go after my husband since we are married? Can they take my house? I only had to sign because I am his wife. Will they go after military pay?

I do know these are a lot of questions for whoever decides to take it, but JAG can't represent me in court and I would really be grateful to anyone who can help with legal advice or fraud advice against this doctor or lawyer. Neither will give me any paperwork to prove my case. Please help.


I got a $1,200 bill from an anesthesiologist for a surgery my daughter had this year. They said they did not have my insurance information, so I gave it to them over the phone. I got a second bill the next month for the same amount. Again, they said the did not have my insurance information, so I gave it to them again.

The next month I get another bill, and they have charged my insurance company $1,632, an increase of $432 from my original two bills. Can they do this legally? This seems really dishonest.


honest suggestion sundown: take them to court. if you can't pay, the judge will allow you to pay what you can a month and they have nothing to say about it.


I stopped working for a company that was paying for health insurance for my family. requested COBRA and they said when my insurance ran out they would send the necessary paperwork. It has been six months now and they just sent me new insurance cards. what do i do? am I in danger of committing fraud?


I doubt they can take your home. Most states have a Homestead Act preventing this. Request an independent medical review from your insurance company. I'm sure they will be forced to pay if you appeal. If you don't feel you can do this alone your health care providers can help.


I've been a widow for three years. I just had a heart attack six weeks ago. my health insurance states that the 3.5 miles to the town hospital, ($3,500.00) is not covered. The helicopter ride to renoun hospital in Nevada, 63 miles away and about 23 minutes air time ($17,000.00) not covered, nor are any of the procedures I had done so far for $65,000.00.

They say there's one more hospital bill I have not received. the only thing that was covered was the room I was in for four days and three nights. I'm afraid they're going to take my house and what money i do have in the bank -- not a lot to live on for the rest of my days.

if I transfer the title of my house to a close friend, I am committing fraud. What is wrong with this picture?

My question was how can I protect my house and money? I tried setting up payments but they said the lowest they will go is $1900.00 a month. any honest suggestions?

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