Medical directors play a crucial role at health insurance companies, serving as the bridge between the medical and insurance worlds. Their responsibilities are diverse and essential for ensuring accurate, fair, and efficient handling of medical claims and policies.
Health insurance fraud, broadly defined, is any deceptive practice by healthcare or healthcare-related providers (physicians, hospitals, clinics, diagnostic testing labs, certain allied health professionals, suppliers of durable medical equipment, etc.) to unlawfully obtain payments from private insurance companies, Medicare and/or Medicaid. These fraudulent activities take a wide variety of forms, bearing witness to the inventiveness of those bent on health insurance fraud. Here are some of the common types, with examples provided for clarification if needed.
In North Shore Medical Center v. Cigna Health and Life Insurance Co. (11th Cir., No. 22-10514, 5/25/2023), the court held that the plaintiff’s expert’s report created a triable issue of material fact, and consequently the district court should not have granted the defendant’s motion for summary judgment. In a concurring opinion, a member of the panel pointed out that one section of the defendant’s expert’s report supported the plaintiff’s position on the triable issue and hence was an independent reason for denying summary judgment.
