In our previous post, “Healthcare Fraud, Abuse and Waste,” we presented the cost of fraud abuse and waste; a detailed description of what it is, what it looks like along with examples; and how it impacts all of us and potential solutions.
Why has this topic received so much media attention recently? First, large amounts of fraud within government programs have recently been discovered and reported by various media outlets. Additionally, several large cases were recently discovered and prosecuted by governmental agencies. It’s no secret that healthcare spending in the U.S. is a very big number. It should not surprise anyone this makes it a target for fraudsters. Fraud, abuse and waste occurs in many different forms from simple approaches to very complex schemes.
In this post, we want to alert you how to protect yourself and your family from becoming a victim. First, we’ll provide a rather simple story of an experience we encountered with someone we knew.
Before we review consumers’ options, I would like to share a story about what a friend experienced. I am Gary Prala, Co-Founder of Healthcare Advocacy Insights. –
This story is not about healthcare fraud, but healthcare providers make many mistakes that contribute to consumers overpaying. Unfortunately, some mistakes are intentional causing healthcare consumers to pay; that is fraud. It is estimated that 10% of the bill’s consumers receive have errors. For example: A friend received a bill from the hospital his daughter was admitted to over $800. He mentioned it to me, and I asked him if he didn’t mind giving me the bill and explanation of insurance benefits for me to audit. What I found was unbelievable: when the hospital received the payment from the insurance company, they misposted the discount (adjustment} the insurance received. The explanation of benefits clearly showed the error. We called the hospital and explained they made an error. The first person we spoke to refused to fix the bill even though we had documentation of their error. We asked to speak to a supervisor. The supervisor was very accommodating and adjusted the bill for $800.
Morale of the story: audit all bills received from healthcare providers before you pay them. You may be surprised by what you find.
Healthcare fraud and abuse is a problem that has not only financial but medical consequences for all healthcare consumers. The following will help you navigate the complex world of Healthcare Fraud, Abuse and Waste.
These numbers are mind-boggling!
Let’s start with how much we spend annually on healthcare
2025 U.S. Healthcare Spending Overview
In 2025, U.S. healthcare spending is projected to reach about
$5.6 trillion, up 7.1°/o from 2024, with hospitals accounting for roughly $1.8 trillion of that total. Healthcare as % of GDP: 18.5% in 2025, up from 17.6% in 2023 Health Affairs.
Now, Let’s Review Healthcare Fraud and Abuse costs
Americans pay $308.6 billion annually just to cover the costs of insurance fraud, according to a 2022 study conducted by the Colorado State University Global White Collar Crime Task Force for the Coalition Against Insurance Fraud. That’s an average of $932.63 for every American or nearly $3,800 for a family of four.
What could your family do with an extra $3,800 a year? Perhaps you’d take a nice vacation, make some improvements to your house or pay down a debt.
Older adults lost $2.4 billion in scams in 2024, four times higher than the
$600 million lost in 2020, according to the FEDERAL TRADE COMMISSION.
Our goal is to explain to consumers how to identify/avoid, combat and report Healthcare Fraud, Abuse and Waste.
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Let’s get going!
HOW TO IDENTIFY AND AVOID HEALTHCARE FRAUD,
ABUSE AND WASTE
To avoid health care Fraud and Abuse start
with protecting your personal information and the following strategies.
Key Strategies to Prevent Health Care Fraud and Abuse:
1. Protect Your Health Insurance and Personal ID’s:
Treat your health insurance ID cards like Medicare, Medicaid and all other insurance cards like a credit card. Do not share your policy number with door-to-door salespeople, telephone solicitors, or online companies. If your card is lost or stolen, report it to your insurance company immediately. Also, make sure you protect your Social Security Number.
2. Be Informed:
Understand the health care services you receive. Keep detailed record of your medical care and review all medical bills carefully.
Ensure that the services billed match the treatments you received.
3. Review Explanation of Benefits (EOB):
Always read your EOB statements and any paperwork from your
Insurance company. Verify that the dates of service and billed services are accurate. Question any suspicious charges or discrepancies.
4. Beware of “Free” Offers:
Be cautious of offers for free health care services, tests, or treatments. These can often be scams designed to bill you and your insurance for services that were never provided.
5. Report Suspected Fraud:
If you suspect you are a victim of health care fraud, report it to your insurance company immediately.
Most insurers provide online options for reporting suspected fraud.
6. Stay Updated on Scams:
Familiarize yourself with common health care fraud schemes, such as unnecessary medical procedures or falsified claims.
Awareness is key to prevention. AARP and your state’s attorney
general office has current information.
The following are several finalized cases relating to scams:
National Partnership of Insurance Brokers and its Former Subsidiary Agree to Pay Over $135 Million For Affordable Care Act Enrollment Fraud Scheme
California Man Pleads Guilty to Orchestrating $270M Medication Reimbursement Fraud Scheme
Business Owner Sentenced to Over Four Years in Prison for $100M COVID-19 Tax Credit Scheme
7. Review your online bank account information at least every couple of days or even daily.
If you get your bank and credit card statements only monthly by paper, make sure you review each transaction, If you’re not able to do this yourself, you can work with someone you trust to regularly review your account information. Examples are: increases in any healthcare payments like you insurance payments, payments to any healthcare provider you did not see, etc….
8. Don’t click on texts and emails that are unclear.
Links in texts and emails can contain viruses. When in doubt, avoid the text or email entirely.
By taking these proactive steps, you can help protect yourself from
healthcare fraud and contribute to the integrity of the health care system.
Remember, health care fraud affects everyone, and being vigilant can help reduce it.
Important Note
A complaint is different from a malpractice lawsuit.
If you are seeking compensation for harm, you would need to consult a medical malpractice attorney.
If you have elderly parents, they are high on the fraudsters’ list of potential targets. Through experience, trial and error and previous success they are very convincing to the unprepared elderly. Be sure to discuss with your parents to be highly suspicious of anyone calling and asking for money, insurance information, etc.
Do you have any personal healthcare stories you like to share with us or any suggestions we can use in our newsletter. Email us at:
Our final newsletter in this series will be how to file a complaint if you think you are a victim of Fraud, Abuse or Waste.