NU Online News Service, March. 4, 2:43 p.m. EST

Of the 14,625 suspected health care fraud reports that the New York State Insurance Department received, 12,807 of them involved the state's no-fault system, according to the insurance superintendent's annual fraud report.

The report notes that suspected no-fault fraud accounted for 53 percent of all fraud reports received in the state during 2010.

"After several years of decline, the number of suspected no-fault fraud reports began to rise in 2007, evening off in 2010," the report says. The number of no-fault fraud reports climbed steadily from 10,117 in 2006 to 13,433 in 2009, before dropping some to 12,807 in 2010.

As for other types of health care fraud reports received, the department said 1,625 of the 14,625 reports involved accident and health insurance, and 193 involved disability insurance. A total of 170 new health care fraud cases were opened for investigation throughout the year, the department's report notes, and Frauds Bureau health care fraud investigations resulted in 159 arrests.

As a response to the no-fault fraud problem, the department said in the report that it is working on an amendment to its no-fault regulation, Regulation 68.

In a separate statement, the department said it is seeking additional public comments on changes to the regulation. The department issued a working draft outlining proposed changes in 2009.

In November 2009, the department said one proposed revision would "simplify procedures required for insurers to suspend all payments for claims submitted by the owner or owners of medical clinics suspected of fraud while an investigation of the clinics' licensing status is underway."

Another proposed revision would modify prescribed forms to require more information, helping to ensure that claims paid are medically necessary, according to the department. The department also said insurers would have greater latitude to deny health services that are not provided or are not billed in compliance with the applicable fee schedule, and thus the payment of fraudulent claims and instances of overbilling would be reduced.

The department has since revised its draft and is looking for more feedback from interested parties. "The department has worked hard to evaluate all of the input we received," said Superintendent James Wrynn in a statement. "The revised working draft reflects that feedback and it is being made available now to give stakeholders another opportunity to review our proposals and submit additional comments."

On the legislative side, State Senator James Seward, R-Oneonta, introduced Senate bill 2816, which would implement tougher penalties on cheaters of the system, modify rules to allow insurers to investigate claims, prevent excessive and unnecessary medical costs, and mandate the use of an arbitrator for disputed claims.

A report from the Insurance Research Council (IRC) at the start of the year said claim abuse appeared to be involved in 35 percent of claims in the New York City area. More than 20 percent appear to be fraudulent, the IRC said.

Special Reports /

No-Fault Makes Up Vast Majority Of 2010 N.Y. Health Care Fraud Reports

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