If you think you have spotted insurance fraud, where you report it depends on the type of insurance involved. This guide covers the warning signs, what to write down, and the places in the United States that take reports.
The Insurance Fraud Association is an independent news and guide site. We do not take fraud reports or pass them on. The channels in this guide are run by insurance companies, government agencies, the National Association of Insurance Commissioners (NAIC) and the National Insurance Crime Bureau (NICB).
What counts as insurance fraud
The NAIC says insurance fraud occurs when an insurance company, agent, adjuster or consumer commits a deliberate deception to obtain an illegitimate gain. It can happen while insurance is bought, used, sold or underwritten.
That covers a wide range. At one end is a policyholder who exaggerates an otherwise legitimate claim. At the other is a fake company or dishonest agent that collects premiums for bogus policies with no intention of paying claims, according to the NAIC.
Key questions to ask before you report
These questions can help you notice when something is wrong.
When you buy a policy
- Is someone rushing you? The NAIC lists intense sales pressure from an agent or broker as a warning sign.
- Is the price far below the rest? The NAIC says premiums 15 to 20 percent lower than other companies' comparable coverage can be a sign that an insurer is not legitimate.
- Can you reach the company? Contact information that is not readily available or easy to find is another warning sign on the NAIC's list.
- Is the seller licensed? Your state insurance department can give you licensing information for a company or agent.
- Did your ID card and policy arrive? If they do not arrive in a timely manner, the NAIC suggests checking with the company that your premiums were applied to your policy.
- Who are you paying? The NICB advises paying by credit card directly to the insurance company, not to an individual, and not with cash or a wire transfer.
When a claim or bill looks wrong
- A health statement lists care you never got. The FBI suggests checking your explanation of benefits regularly to make sure the dates, locations and services billed match what you actually received.
- A free service asks for your insurance number. The FBI warns that if you are asked for your health insurance information for a service described as free, the service is probably not free and could be fraudulently charged to your insurance company.
- A contractor promises repairs after a disaster. The NICB says fraudulent contractors may try to claim their victims' insurance benefits by promising work they never intend to complete.
- A tow truck rushes in after a crash. The NICB warns about predatory tow trucks that swoop in while motorists are vulnerable and leave them on the hook for overinflated charges.
- Someone inflates a claim. The NICB's examples include consumers who exaggerate the cost of their insurance claims or submit repairs that did not result from a covered event.
If you notice one of these signs, ask questions. If the answers do not add up, report it.
What to write down before you report
Specific details help investigators. The HHS Office of Inspector General says its investigations are most successful when you provide as much information as possible. This list draws on what HHS and the FBI ask for:
- The name and contact details of the person or business involved, such as an address, phone number or email address.
- What happened, when it happened, and how you learned about it.
- Key dates, such as the date of service, the date of a claim, and the dates of any calls or payments.
- The name of the insurance company involved.
- Copies of supporting documents, such as bills, explanation of benefits statements, emails or photos.
- The names of anyone who can back up what you report.
- Any other agency you have already told, and any reference number it gave you.
Keep your originals. The FBI advises keeping original documents, emails and logs of communication when possible, and attaching copies or photos to your complaint. The HHS hotline also asks you not to mail original documents, because they will not be returned.
Where to report insurance fraud
Match the channel to the type of insurance. If you are not sure where your case belongs, start with your state insurance department. The NAIC advises anyone who is aware of fraudulent activity to contact the state insurance department or file a report through its Online Fraud Reporting System.
| If the fraud involves | Report it to |
|---|---|
| A policy or claim with a specific insurer | That insurance company's special investigations unit |
| Any type of insurance in your state | Your state insurance department or fraud bureau |
| Inflated claims, contractor fraud after disasters, medical billing schemes or vehicle theft rings | The National Insurance Crime Bureau |
| Medicare or Medicaid | The HHS Office of Inspector General |
| Medicaid providers in your state | Your state's Medicaid Fraud Control Unit |
| Private health insurance | Your health plan's special investigations unit, or the FBI at ic3.gov |
| Social Security disability benefits | The Social Security Office of the Inspector General |
| Workers' compensation | Your state fraud bureau, the insurer, or your state workers' compensation agency |
The insurance company's special investigations unit
Most insurers have set up special investigation units, or SIUs, to help identify and investigate suspicious claims, according to the Insurance Information Institute (Triple-I).
Contact the company directly. The National Health Care Anti-Fraud Association notes that most insurers now let you report suspected fraud online through their websites.
Your state insurance department or fraud bureau
The NAIC keeps a map of insurance departments for all 56 U.S. insurance jurisdictions, with contact information and a way to file a complaint. Those jurisdictions are the 50 states, the District of Columbia and five U.S. territories, whose chief insurance regulators govern the NAIC.
Most states also have a special fraud bureau that investigates insurance fraud. These bureaus take referrals from sources such as law enforcement agencies, insurance companies and consumer complaints, the NAIC says. As of March 2020, 42 states and the District of Columbia had an insurance fraud bureau, and most of them deal with all lines of insurance, according to the Coalition Against Insurance Fraud.
You can also file online through the NAIC's Online Fraud Reporting System, which lets consumers send information about possible fraud to their state agency.
If your problem is how an insurer handled your claim or set your rate, that is usually a complaint rather than fraud. Your state insurance department takes complaints about insurance companies and agents too.
The National Insurance Crime Bureau
The NICB is a not-for-profit organization dedicated to fighting insurance fraud and crime. It takes tips about suspected insurance fraud by phone and online. Call 800-TEL-NICB (800-835-6422), Monday through Friday from 7 a.m. to 7 p.m. Central time, or fill out the form on its report page.
You can leave a tip anonymously. If you do give your name and contact details, the NICB notes that you could be named as the provider of the tip if its records are subpoenaed or required by a court.
The NICB does not handle concerns about an insurance company's service or rates, and it asks you to take those to your insurance provider.
Medicare and Medicaid fraud
The HHS Office of Inspector General takes tips about fraud in Medicare, Medicaid and other HHS programs, including false claims, kickbacks and medical identity theft (HHS-OIG). File online at tips.oig.hhs.gov or call 1-800-HHS-TIPS (1-800-447-8477).
Questions about Medicare coverage, a Medicare bill or a lost or stolen Medicare card go to Medicare instead, at Medicare.gov or 1-800-MEDICARE (HHS-OIG). Medicare's fraud page also lists 1-800-MEDICARE (1-800-633-4227) for reporting suspected fraud.
Every state, the District of Columbia, Puerto Rico and the U.S. Virgin Islands has a Medicaid Fraud Control Unit that investigates and prosecutes Medicaid provider fraud, along with abuse or neglect of residents in health care facilities. The National Association of Medicaid Fraud Control Units links to each state unit and asks you to report through your state unit's website, not to the association.
Other health insurance fraud
For fraud involving private health insurance, contact your health plan's special investigations unit, which the Medicaid Fraud Control Units' association lists as a reporting channel. You can also report to the FBI, which says it is the primary agency for investigating health care fraud in both federal and private insurance programs. The FBI's health care fraud page asks you to file a complaint with its Internet Crime Complaint Center at ic3.gov.
Social Security disability fraud
The HHS Office of Inspector General says disability fraud should be reported to the Social Security Administration's Office of the Inspector General. Its report page covers problems such as giving false or misleading information to get or keep benefits, hiding eligibility factors like work, earnings, disability or living arrangements, and misuse or fraud by a representative payee.
Workers' compensation fraud
Workers' compensation fraud can involve a worker, an employer or a medical provider. Triple-I's examples include claiming a job-related injury that never occurred, working while allegedly disabled, a provider billing for procedures that were never performed, and an employer misrepresenting payroll to pay lower premiums.
Report it to your state insurance fraud bureau or to the insurance company handling the claim, or check with your state's workers' compensation agency. The U.S. Department of Labor keeps a directory of state workers' compensation officials. Some states have more than one fraud bureau to address fraud in different lines of insurance.
What happens after you report
At the HHS Office of Inspector General, not every complaint leads to an investigation, and the hotline cannot confirm receipt of a complaint or tell you what action it took. If you identified yourself, a reviewing official may contact you for more information, and HHS says that not being contacted does not mean your complaint is not being investigated.
You can often choose how much of your identity to share. HHS offers three options: no restrictions, confidential, or anonymous. It warns that keeping your identity confidential or anonymous can make it harder to review and resolve your complaint (HHS-OIG).
If someone is in danger or has a medical emergency, call 911. The HHS hotline says to dial 911 for a medical emergency, the NICB asks you to report emergencies and dangerous activity to local law enforcement, and the Medicaid Fraud Control Units' association points out that its units are not first responders.
Do insurers have to report fraud too?
In most states, yes. As of March 2020, 43 states and the District of Columbia required insurers to report suspected fraud to the state fraud bureau or another agency, according to the Coalition Against Insurance Fraud.
Insurers can also hand bigger cases, such as organized fraud rings or people who stage crash after crash, over to the NICB. Its people build those cases so prosecutors can take them to court, and they connect insurers with the police (Triple-I).