that harm patients. Medical providers who cheat insurers also tend to cut corners on patient care.
WASHINGTON, D.C.—The Coalition Against Insurance Fraud took two U.S. Senators to task recently for discouraging insurance industry actions to thwart medical fraud. Senators John Rockefeller (D-W. Va.) and Al Fran-ken (D-Minn.) independently opined that regulations being crafted on medical loss ratios shouldn’t include insurer costs for anti-fraud activities. The ratios are mandated by the new health reform act, which requires insurers to spend a set percentage of consumer premiums they receive for the purpose of reimbursing medical providers and on programs that address quality of health care. In letters to the pair, the Coalition argues that fraud directly relates to health-care quality.
day involving the Health Care for America Now (HCAN) report suggest that you oppose the idea of including anti-fraud expenses in medical loss ratios for health plans.
“In fact, an investigation by private health insurers uncovered the nation’s largest medical fraud scheme in 2007. Surgical centers in California performed unnecessary and risky surger-ies on more than 2,800 patients, some of whom are scarred for life.
“Departments have stepped
up anti-fraud efforts and
reached out to private
insurers to collaborate on
fighting organized medical
fraud rings, it would be
counterproductive to
discourage anti-fraud activities.”
“We can share with you many other cases where rogue medical providers have been brought to justice thanks to private insurer investigations.
“Your comments in news reports to-
“Excluding expenses for combating
fraud is an unhealthy idea. Fighting
fraud has direct consequences for the
quality of health care. Through inves-
tigations of suspect health claims, in-
surance company investigators often
uncover treatment and procedures
“Robust investigations by private
health plans help ensure that consum-
er premiums go to needed health care,
and not to scam artists who steal tens
of billions of dollars through medical
fraud every year.
“Excluding anti-fraud expenses from medical loss ratios would discourage insurer investment in this needed area. While most health plans are dili-
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