insurance fraud

Like sand through your fingers, fraud can cost millions in losses.

There’s a group of people who really love the U.S. health care system — the fraudsters! Like sand through your fingers, fraud can cost untold money losses for your company. Today’s smart business companies must focus on protecting their assets through proactive measures to identify insurance fraud.

Hiring a Case Manager (CM) and or Legal Nurse Consultant (LNC) can help to identify both provider and claimant insurance fraud. The knowledge they provide can save your company thousands of dollars per case.

We all know that false claims cost your company millions of dollars a year but providers are habitual offenders as well. The health care providers who commit these fraud schemes encompass all areas of health care, including hospitals, home health care, ambulance services, doctors, chiropractors, psychiatric hospitals, laboratories, pharmacies, and nursing homes. Violators may be prosecuted under: 18 U.S.C. 1347 Health Care Fraud.

Case Managers’ and Legal Nurse Consultants’ education and experience come directly from working within the health care system and because of that they can identify many fraud indicators that an insurance adjustor might miss, whether it’s a claimant or a provider. CMs and LNCs represent powerful tools, so why would an adjuster not use all the tools available? That’s a good question but only the adjuster can answer it.

Case Managers Play Critical Role In Identifying Provider Fraud

This is because they actually work with the patient and some of the patient’s providers. They’re able to verify if the patient’s needs are being met through observing if the patient has the proper medication, equipment, diagnostic testing and services.  They act as your very own Private Detective, so to speak. CMs can alert you to red flags such as:

  • Billing for services not rendered.
  • Billing for services performed by a lesser qualified person.
  • Misrepresenting procedures performed to obtain payment for non-covered services.
  • Billing for a more costly service than the one actually performed.
  • Billing each stage of a procedure as if it were a separate procedure.

Legal Nurse Consultants Play Critical Role In Identifying Claimant Fraud 

claimant insurance fraud

LNCs and CMs provide valuable insight to the claims table.

Legal Nurse Consultants are highly educated have state licensing as Registered Nurses. As such, they have much to offer at the claim negotiating table. Their vast medical knowledge and experience can provide an insurance adjuster with valuable insight into reducing the monetary claim demand. LNCs can alert you to red flags such as:

  • Pre-existing conditions.
  • Varying diagnostics results.
  • Over utilization of services.
  • Exaggerated symptoms.
  • Malingering behaviors.
  • Drug seeking behaviors.
  • Analysis of ambiguous and subjective symptoms.

Case Managers and Legal Nurse Consultants can be worth their weight in gold. Your gold! An average CM case costs approximately $1200.00 a month. An average LNC report cost approximately $900.00. These tools can save you and your company thousands of dollars and sometimes tens of thousands of dollars. Do yourself and your company a favor and take back your gold from the fraudsters! Hire a Case Manager or LNC. You just might get a BIG BONUS.