US: Medical Mutual battles healthcare fraud

Armed with some nifty software and a small, but ambitious staff, John Shoemaker, manager of Medical Mutual of Ohio's Financial Investigation Unit uncovered $4.9 million in fraudulent activity for the year ending 2007, according to figures just released by the Cleveland-based health insurer.

On average, Shoemaker and his staff investigate 120 cases of potential fraud per year and have produced more than 700 indictments in 20 years. Over the past five years, Medical Mutual has reclaimed more than $20 million from fraudulent activity.

The costliest of all crimes, the National Health Care Anti-Fraud Association (NHCAA) estimates more than $100 million is lost every day to health insurance fraud. Shoemaker and the NHCAA said everyone pays for health insurance fraud and there are ways consumers can help prevent it:

Protect your health insurance card like your credit card. In the wrong hands, a health insurance card is a license to steal. Don't give policy numbers or other identifying information to door-to-door salesmen or telephone solicitors.

Read your policy and benefits statements. Read your policy, Explanation of Benefits (EOB) statements and any paperwork you receive from your insurance company. Make sure you actually received the treatments for which your insurance was charged, and question suspicious expenses.

Beware of "free" offers. Offers of "free" services are often fraud schemes designed to bill you and your insurance company illegally for thousands of dollars of treatments you never received. If it sounds "too good to be true," it usually is.

Report fraud quickly. Don't put it off. Call your insurance company immediately if you suspect you may be a victim of health insurance fraud.

According to the NHCAA, health insurance fraud is responsible for upwards of five percent of the total cost of all health care in the United States annually. "Our mission is to simply try to help hold the line against higher health care costs," said Shoemaker.

Shoemaker said the fraud-sniffing software plays a huge part in nabbing health insurance fraud artists by flagging irregularities in insurance claim filings. "This software helps us focus efforts on cases most likely to have fraud," said Shoemaker. "This year, the company has almost five million reasons to believe our staff and software are working quite well together."

Founded in 1934, Medical Mutual of Ohio is the oldest and largest health insurance company based in Ohio. The company serves its customers through high-quality, affordable group and personal health insurance plans, and third- party administrative services to self-insured group customers. Based in Cleveland, Medical Mutual also has offices in Columbus, Cincinnati, Toledo, Akron, Dayton and Youngstown. For more information, visit the company's award- winning Web site at MedMutual.com.

Source: Medical Mutual of Ohio