What is Healthcare Fraud?

Healthcare fraud is an umbrella term for schemes that defraud medical systems of money or drugs: phantom billing, upcoding, unbundling, kickbacks, prescription mills, identity theft for care, and durable‑medical‑equipment scams. The activity places burden on insurers, public programs, and patients whose identity is abused in bogus claims.

Signals: signatures include volume of the same procedures for many patients or by providers billing outside of specialty norms, prescriptions clustered to amenable pharmacies, phone numbers and addresses reused across “separate” beneficiaries, and policy-linked spikes. Stolen medical identities are more durable than cards—victims pay long after replacement.

Controls: validate provider and patient identity stringently at onboarding and sensitive updates with identity verification; review claims against risk scoring that blends medical policy rules and contextual graphs; and coordinate investigations and reporting into money movement with AML compliance processes where appropriate. Empower patients to review EOBs, freeze accounts on anomalies, and carefully share information with sketchy apps.

Care is fragile. Keep the trust chain intact—identity, claim, payout.