If you suddenly found yourself working for an insurance company and received a claim that looks like this for MRI--

[Silent Type]

19. You know who gets scammed the most -- MEDICARE.

Here's an example--

Twenty-Three Individuals Charged in $61.5 Million Medicare Fraud Schemes

Tuesday, February 7, 2023

Office of Public Affairs

Court documents were unsealed this week charging 23 Michigan residents for their alleged involvement in two illegal schemes to defraud Medicare of more than $61.5 million by paying kickbacks and bribes and billing Medicare for unnecessary medical services that were never provided.

“As alleged, the defendants and their co-conspirators repeatedly paid illegal bribes and kickbacks so they could submit claims for medically unnecessary home health services throughout the Detroit metropolitan area, exposing patients to needless physician services and drug testing and costing Medicare tens of millions of dollars,” said Assistant Attorney General Kenneth A. Polite, Jr. of the Justice Department’s Criminal Division. “As these actions demonstrate, we will work tirelessly to tackle complex, illegal schemes that take advantage of vulnerable populations and defraud federal programs of taxpayer dollars meant to provide health care to millions of Americans.”


https://www.justice.gov/opa/pr/twenty-three-individuals-charged-615-million-medicare-fraud-schemes

I could provide many more. But if someone gives a darn, they can go to the site above and read about thousands examples of improper billing and fraud.

How does this happen? Medicare is often passive often pursing improper claims by "pay and chase," thus not denying as many claims up front as private insurers do. If we are lucky Medicare catches these a few years down the road.

Private insurers are more aggressive up front, preferring not to pay before making sure it's legit. Yeah, sure, sometimes they are just trying to keep doctors from billing Botox as treatment for headaches, when it's really to smooth your forehead.