What to do if member fraud is suspected

A patient comes into your clinic for treatment and presents a plan identification (ID) card identifying her as the dependent spouse under her husband's managed care plan. But you overhear her telling an employee that they aren’t really married. The ID card is in her correct name but a different last name from the "husband's." If you suspect that she isn’t a covered plan member, can you simply refuse to accept the ID card outright and insist that she pay in cash, as if she wasn't covered? Here is what you should do:

  • Follow your regular procedures for verifying a patient's plan coverage before taking the position that the patient isn't covered. If you don't, you run the risk of wrongly accusing a member of fraud and violating your plan contract for demanding cash payments from a covered member, warns Atlanta consultant Karen M. Beard.
  • Remember that an increasing number of employers are allowing employees to add domestic partners as dependents to their health insurance coverage, even if they aren't married. So you can't assume that a patient is committing fraud and summarily treat him or her as noncovered.
  • If the plan ID card is in the patient's correct name, "then it's less likely that fraud is involved," Beard notes.
  • To protect yourself, follow your regular procedures for verifying coverage with the plan. If the plan verifies coverage and the patient's information matches what the plan has, including the date of birth, Social Security number, and other important information, it's reasonable to assume that the ID card is valid, says Beard.
  • Compare the information on the ID card with the patient's other identification, such as a driver's license or similar photo ID. If you still can't verify that the ID card is valid or you suspect that the patient isn't really a covered plan member, ask for cash up-front."If you can show a plan that you tried to verify coverage before treating the patient as noncovered, then even if it later turns out that you were wrong, the plan will be much less likely to accuse you of violating your contract," Beard explains.This tip was excerpted from HCPro's monthly newsletter, Managed Care Contracting & Reimbursement Advisor. For more information, click here.

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