CFE – Financial Transactions and Fraud Schemes — Question 99
Which of the following scenarios is the MOST ACCURATE example of insurer health care fraud?
Answer options
- A. After negotiating discounts with its medical providers, the insurance company provides the negotiated rate to its consumers instead of the original amount.
- B. To obtain regulatory approval for increasing its rates, the insurance company submits inflated cost data for review.
- C. Upon identifying that a claimant has provided incomplete information, the insurance company refuses to pay a claim.
- D. While acting as an intermediary for a government health care program, the insurance company verifies provider claims before billing the government for them.
Correct answer: B
Explanation
Option B is correct because submitting inflated cost data to obtain regulatory approval constitutes fraudulent behavior aimed at manipulating rate increases. The other options do not reflect fraudulent actions; they describe legitimate business practices or responses to incomplete information.