How Do You Get Private Insurers To Do Their Job?

I recently summarized an article about how lackadaisical insurance companies are when it comes to health care fraud. This time let’s talk about how we can make them take it seriously!

Private health insurers should report fraud that happens in their networks, right? Its common sense to think that these companies will report the fraudsters and highlight their schemes. By law, they must report physicians or mid-levels billing insurers for services they never provided or hospitals upcoding to maximize their profits or even worst, a fraudster targeting several insurers pretending to be a medical professional, as I outlined in my previous article.

So what happens when fraud is noted? Most insurers prefer to handle suspicious cases internally without notifying prosecutors or regulators. Why should they? They just pass on the lost money to employers and working Americans, causing premiums to skyrocket! After all, the premium in 2019 for a family was $19,500 and in 2020 its expected to go up to $20,000. 

So what can you do to make sure insurers are doing their job? Sad, isn’t it?

Let’s encourage regulators to randomly audit the claims received by private insurers and fine the insurers for failing to report any fraud or rather start putting people behind bars. If you find them, what do you think they will do? Up the premiums! I think its time to put people who break the law, where they belong, which will send a more serious message!

Next, we should require that any case suspected of fraud should be reported to regulators nationwide, since neither the federal government, which regulates self-funded plans in which an employer funds the plan and hires an insurer or other company to process medical claims, nor more than a dozen states require reporting suspected cases. After all, more than 150 million Americans who get their benefits at work are covered by self-funded plans! 

Lastly, give employers who fund their companies’ health benefits detailed information about spending, so they can spot suspicious trends. I find it odd, though not surprising, that the one paying doesn’t know where the money is going.

Or better than all of the above, employers should consider contracting with Direct Primary Care Physicians whom will not only provide exponentially better care than the existing system, but most important of all, cost transparency? Don’t believe me? Check out the savings of Union County, North Carolina.

In what field do you do business not knowing what the cost will be until after the spendings are exhausted? 

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