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If stuff like voluntary plastic surgery wasn't covered, what the hell kind of medical fraud would there be? We have OTHER systems to find doctors prescribing d

If stuff like voluntary plastic surgery wasn't covered, what the hell kind of medical fraud would there be? We have OTHER systems to find doctors prescribing drugs, so wtf does insurance provide the consumer except a pathway to debt?

gruez 2y ago
>If stuff like voluntary plastic surgery wasn't covered, what the hell kind of medical fraud would there be? Off the top of my head: going to a doctor, conspiring with him to make an insurance claim that you had some sort of procedure done even though none was actually done, and splitting the claim check? Not saying this happens, but it's not hard to think of frauds you could perform even if "voluntary plastic surgery wasn't covered".
- fernmyth 2y ago
  There's no reason for the doctor to involve any patients, other than to write their names down. These are fraud factories submitting thousands of templated claims per year.
  - gruez 2y ago
    >There's no reason for the doctor to involve any patients, other than to write their names down. ...until the patient looks at his health insurance account and notices a charge that he doesn't recognize, or the insurance company decides to do a random audit of a claim.
    - SpicyLemonZest 2y ago
      Right, it's true that insurance companies investigating and denying claims is a major constraint on claims fraud. That's why Medicare and Medicaid still deny a lot of claims (although not so many as UHC) despite being publicly run.
- Enginerrrd 2y ago
  Or there's things like doctors ordering dozens of tests to identify a particular cold virus even though it wouldn't change the treatment or patient outcome, and oh, it just so happens the doctor owns the lab. (A real example) Or a doctor prescribing a monthly massage to a patient. Or approving a questionable disability claim. etc. etc. Fraud finds a way to happen.
SpicyLemonZest 2y ago
You can peruse Medicare fraud prosecutions for all kinds of scenarios. See for example https://www.justice.gov/archives/opa/pr/doctor-sentenced-54m-medicare-fraud-scheme https://www.justice.gov/archives/opa/pr/doctor-sentenced-54m.... If you convince a confused elderly person that they need some device, and submit paperwork falsely certifying you agree they need it, that's not trivial to detect.
- tekno45 2y ago
  so how does the health insurance system stop this?
  - SpicyLemonZest 2y ago
    That’s what a claim denial is. If you dig into the details of a viral claim denial story of your choice, you’ll almost always find the same dispute: the insurance company thinks the doctor prescribed an expensive treatment when a simpler treatment would have worked just as well. I don’t mean to overstate the argument. Claim denials are a terrible way to resolve disputes like this, because they inflict quite a lot of pain and stress on the helpless patient who did nothing to cause it and can’t meaningfully help resolve it. But it’s important to understand why simply telling insurance companies to stop denying claims, despite its intuitive appeal, isn’t a real option.

gruez 2y ago

>If stuff like voluntary plastic surgery wasn't covered, what the hell kind of medical fraud would there be? Off the top of my head: going to a doctor, conspiring with him to make an insurance claim that you had some sort of procedure done even though none was actually done, and splitting the claim check? Not saying this happens, but it's not hard to think of frauds you could perform even if "voluntary plastic surgery wasn't covered".

fernmyth 2y ago
There's no reason for the doctor to involve any patients, other than to write their names down. These are fraud factories submitting thousands of templated claims per year.
- gruez 2y ago
  >There's no reason for the doctor to involve any patients, other than to write their names down. ...until the patient looks at his health insurance account and notices a charge that he doesn't recognize, or the insurance company decides to do a random audit of a claim.
  - SpicyLemonZest 2y ago
    Right, it's true that insurance companies investigating and denying claims is a major constraint on claims fraud. That's why Medicare and Medicaid still deny a lot of claims (although not so many as UHC) despite being publicly run.
Enginerrrd 2y ago
Or there's things like doctors ordering dozens of tests to identify a particular cold virus even though it wouldn't change the treatment or patient outcome, and oh, it just so happens the doctor owns the lab. (A real example) Or a doctor prescribing a monthly massage to a patient. Or approving a questionable disability claim. etc. etc. Fraud finds a way to happen.

SpicyLemonZest 2y ago

You can peruse Medicare fraud prosecutions for all kinds of scenarios. See for example https://www.justice.gov/archives/opa/pr/doctor-sentenced-54m-medicare-fraud-scheme https://www.justice.gov/archives/opa/pr/doctor-sentenced-54m.... If you convince a confused elderly person that they need some device, and submit paperwork falsely certifying you agree they need it, that's not trivial to detect.

tekno45 2y ago
so how does the health insurance system stop this?
- SpicyLemonZest 2y ago
  That’s what a claim denial is. If you dig into the details of a viral claim denial story of your choice, you’ll almost always find the same dispute: the insurance company thinks the doctor prescribed an expensive treatment when a simpler treatment would have worked just as well. I don’t mean to overstate the argument. Claim denials are a terrible way to resolve disputes like this, because they inflict quite a lot of pain and stress on the helpless patient who did nothing to cause it and can’t meaningfully help resolve it. But it’s important to understand why simply telling insurance companies to stop denying claims, despite its intuitive appeal, isn’t a real option.