Medicare Compliance & Reimbursement

Question: Is medical identity theft a type of fraudulent claim?

Minnesota Subscriber

Answer: Identity theft is the theft of personal, private, financial information for some type of individual gain, says Kelly A. Shew, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, CEMC. Medical identity theft is when a person uses someone else’s information, including their insurance policy, to get services for themselves. Fraudulent claims are for services that were not actually rendered or weren’t medically necessary — it’s either billing services to patients who don’t need them or billing for services that weren’t provided, Shaw says.

Some situations in which people have been victims of medical identity theft include incidents where their information is used to procure prescriptions for opiates or medical supplies. In these situations, if a payer covers the services and then finds out they were fraudulent, the insurance company tends to recoup their costs, leaving the clinician and health system with the costs, Shaw says.

These situations tend to be expensive for everyone involved, so patients and practices should do what they can to secure their protected health information (PHI).