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Insurance Regulators Work to Protect Consumers from Fraud

Source: NAIC


Posted on 29 Jan 2010

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State insurance regulators put fighting fraud at the forefront during a national dialogue on combating health care abuses. Four members of the National Association of Insurance Commissioners (NAIC) were panelists at the National Summit on Health Care Fraud sponsored by the U.S. Department of Health and Human Services and the U.S. Department of Justice. During the Summit, regulators addressed various ways to fight fraud in Medicare, Medicaid and private insurance markets.

"Protecting consumer information from medical identity theft will help both consumers and the industry. We must prevent payments by insurance carriers or the government for fraudulent services," said Sandy Praeger, Kansas Insurance Commissioner, who chairs the NAIC's Health Insurance and Managed Care Committee. "Billing for services not performed and falsely creating a patient's health history are a costly source of waste and abuse."

"Providers who engage in fraud, waste and abuse should be decertified and insurers must adopt antifraud plans under the guidance of state regulators," said Jane Cline, NAIC President and West Virginia Insurance Commissioner. "Legislative reform should address the need for plan administrators or providers to have an active antifraud plan." She noted that the NAIC is in the process of drafting a guideline for antifraud plans that will assist companies without an antifraud plan as well as states that have not adopted antifraud plan language in their regulation or code.

During the Summit, Ohio Insurance Director Mary Jo Hudson addressed effective law enforcement strategies. She advocates stiffer penalties for those found to have committed health care fraud. "Increased fines, jail time and other measures should be introduced in order to decrease monetary losses and reduce waste and abuse." Hudson recommended the federal government and state insurance departments work together to allow shared access to databases to help combat insurance fraud.

Illinois Director of Insurance Michael T. McRaith discussed the importance of state insurance departments in combating fraud. "As the first line of defense against health insurance fraud, regulators coordinate with law enforcement to process complaint referrals, and investigate and prosecute allegations of insurance fraud. Providers who intentionally bill for services not medically necessary or bill for services not provided should be vigorously prosecuted," he said.


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