August 3, 2021

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Fraud unit sees record number of fraudulent insurance claims this year

3 min read

The onslaught of fraudulent medical records began with a case in which an entire family, young children included, claimed they had been in separate ATV accidents that each warranted a significant surgery.

Brendan Harris, the acting fraud director of the NH Insurance Department, received the case about a year ago, a couple of months into the pandemic.

“We finally put it on the spreadsheet and it’s like nobody could have that many surgeries in one year,” he said. “All they had to do was change a few items on the medical form, send it in and make 12,000 bucks.”

This was just one fraud case from a record-breaking year for the fraud unit of the NH Insurance Department. In total, the department investigated and submitted 18 cases for criminal prosecution, six more than the fraud team aims for during an average year. The defendants in these cases are allegedly responsible for defrauding $333,000, which, the department said, would have unfairly raised premiums for Granite Staters if they had not been caught.

The 18 cases doesn’t fully represent how many instances of fraud there have been this year. The department has to be selective about which cases they bring to court. Harris said the department reviewed about 300 referrals from insurance offices in the last 12 months.

The subject of the fraudulent claims varied – false claims of missing jewelry, fake disability claims, misrepresented dates of car accidents. Mostly, the department sifted through what they called “an abundant amount of fake medical records.”

“I’ve never seen so many fake medical record cases in the 13 years I’ve been here,” he said. “Every case you got had some sort of altered medical record to it.”

Harris said he blames the pandemic. People had lots of time on their hands to doctor documents and access to work computers loaded with the software to do it – a quarantine project of sorts.

He said insurance companies were also partly to blame. Quarantine had eroded the staff’s ability to thoroughly investigate claims.

“It used to be people sitting around in the same area of a cube city and (they) could be discussing stuff and bouncing ideas off of each other,” he said. “Now everybody was sort of siloed into their home office and they were just paying the claims.”

He said several cases he’s worked this year mirror the case that involved the alleged ATV accidents. The defendants often doctor documents not only for themselves, but for many of their immediate family members. In one case from the last year, a woman from Lisbon submitted disability claims for herself, her kids, and her kids’ kids, collecting about $80,000.

The altered medical record scheme is a relatively new phenomena that has just started picking up traction in the last few years, he said. He isn’t sure exactly what has prompted the trend but suspects it has something to do with how advanced editing software has become.

“I examined them for a long time and I could not tell they were doctored,” he said. “Technology is getting really good.”

Many of the culprits worked in medical billing and knew exactly how medical records should look, he said. Some even generated fake certification forms so that when insurance agents received the documents, they didn’t call the named hospital to confirm the forms’ veracity.

“They knew what wording to put in there and what CPT diagnosis codes to put in there,” he said. “They would have had access to tons of real medical records and go ‘okay this is what they’re supposed to look like.’”