A couple of dumb nobodies bilked Medicare for almost a billion dollars before they got caught. Nothing in that Propublica article gets within an order of magnitude.
Also, just looking for fraud complaints is missing the way most insurers combat fraud: They have enough systemic protections to deny the claim in the first place.
ProPublica has done an extensive series on this; at least a skim is worth it. Even the industry doesn’t claim to be as effective at combating fraud as you do.
> While Pratte, Lankford and some of Williams’ clients repeatedly flagged bogus bills, the mammoth health insurers reacted with sloth-like urgency to the warnings. Their correspondence shows an almost palpable disinterest in taking decisive action — even while acknowledging Williams was fraudulently billing them.
> In September 2015, United wrote to Williams, noting his lack of a license and the resulting wrongful payments, totaling $636,637. But then the insurer added a baffling condition: If Williams didn’t respond, United would pay itself back out of his “future payments.” So while demanding repayment because Williams was not a doctor, the company warned it would dock future claims he would be making as a doctor.
> In November 2016, United investigators caught Williams again — twice. They sent two letters accusing him of filing 820 claims between May 2016 and August 2016 and demanded repayment. Again, almost inconceivably, the company threatened to cover his debt with “future payments.”
> Fraud in government programs, like Medicare and Medicaid, gets more publicity, he said, and has dedicated arms of agencies pursuing fraudsters. But the losses may be even greater in the commercial market because the dollar levels are higher, he said.
> He called fraud investigators from Aetna, Cigna and United, who testified that their companies auto-pay millions of claims a year. It’s not cost effective to check them, they said. “Aetna relies on the honesty of the person submitting the claim verifying that it’s true,” testified Kathy Richer, a supervisor in Aetna’s Special Investigations Unit.
Big catches make for splashy headlines, but for every $2B case that makes national headlines there are a whole bunch of these $25M cases they can’t be bothered to notice.
Why would you care about fraud if you can just raise premiums to cover it? My insurer just sent me a letter saying they’re applying for a 21% increase in my $3k/month health insurance policy for next year.
Still looking for that 9-figure scam run by (apparently) morons.
Are you or Propublica making the claim that private insurers pay out the majority of their claims on trust? Generally we hear the opposite, that they’re looking for any excuse to deny.
"Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion."
> Are you or Propublica making the claim that private insurers pay out the majority of their claims on trust?
That claim is made, under oath, by a "supervisor in Aetna’s Special Investigations Unit".
In a case where the insurers were repeatedly willing to be reimbursed from future payments to a provider they knew was unlicensed, no less. Where were the magical "systemic protections" that private insurers have nearly perfected while Medicare supposedly lacks them entirely?
Also, just looking for fraud complaints is missing the way most insurers combat fraud: They have enough systemic protections to deny the claim in the first place.