Healthcare Fraud

This weekend I received a letter saying that my request for “Testosterone 1.62% gel pump” was denied. The letter has all my correct information as well as my healthcare member ID correct. My “insurance” is self insured through my company and every dollar the healthcare plan pays out is a dollar to the expense line and a dollar that my company pays. I sent this to the healthcare/claims department to report as potential fraud.

The provider is not someone that I am familiar with. I rarely go to a third party doctor as my work has a onsite clinic that I don’t have to pay to see nor do I need to make an appointment.

My initial though is some provider has been hacked and medical and or billing information has been hacked. Now a fraudster is trying to get money out of the insurance company. It could also be an honest mistake where a provider with multiple doctors got their wires crossed. I don’t know yet but this is going to be a real pain in the ass as my insurance company will likely issue me new ID. It’s not a big deal for me buy my wife sees boat loads of doctors.

There were 3-4 companies in the news in the last couple of days for this kind of fraud, billing for things that didn’t happen or shouldn’t have happened. I’d call the insurance company at least.


Update. The healthcare claims person called me. Apparently there is a clone of me with same name and birthdate in a different state. He does have a different SSN and mailing address. The clearinghouse used to process the RX claims is used by both my company and his company. The wires got crossed and his LowT gel pump got processed on my healthcare number. The claims lady said, they have identified other claims from my clone that our healthcare plan has paid in the past. Who knows if any of my claims have ever been processed under him.

Are your first and last names fairly common? If so, the fuzzy match they’re doing may result in this often.