Mar 3, 2026
Trust is an integral part of a relationship with a medical provider and realizing that trust has been abused can be an upsetting experience.
Imagine the case of Cali, who has been seeing the same dentist for four years. Last year, she had to have emergency dental work done and before the procedure, her dentist’s office told her the procedure would be covered by her insurance.
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However, following the dental work, the office told her that her benefits were maxed out and that they could “help her out” to lower the cost of the dental bill to $3,000 by billing the procedure under a different code with the insurance. This code included other work Cali never received though she would still be required to pay $3,000 out of pocket.
Cali was shocked, since she had specifically checked before the procedure whether the emergency work was fully covered.
Cali told the office she was unwilling to pay out of pocket for work that should have been covered and for work she never received and contacted her insurance provider to complain.
Months later, Cali was reviewing her EOB and saw that the procedure had been paid for by her insurance and that it had been billed as a different procedure than what she received.
She reached out once again to her insurance provider to tell them what the dentist’s office had done. This time, her insurance provider got back to her and confirmed that the dentist’s office had made a fraudulent claim.
Unfortunately, such scenarios can happen. Health care fraud can take many forms; it can be committed by patients as well as other individuals — and even by health care providers.
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According to the FBI, health care fraud costs tens of billions of dollars in losses a year and its effects are wide reaching. It impacts both individuals and businesses and could mean hikes to insurance premiums, higher taxes or even unnecessary medical procedures (1).
In Cali’s case, the dentist’s office contacted her, demanding she pay the $3,000, or they would send the amount owing to collections. However, when Cali asked the dentist’s office for an itemized bill, they failed to provide it.
It’s a worrying scenario. But if you had a medical provider make a threat like this, there are steps you could take to protect yourself. Here is what you need to know.
What is health care fraud?
According to the FBI, health care fraud committed by individuals includes bogus marketing, where scammers convince people to provide their health insurance identification number and personal information. This data could then be used in identity theft, billing for services that were never rendered or to enroll them in a fake benefit plan (1).
Other health care fraud by individuals includes identity theft or identity swapping, which involves using someone else’s health insurance or letting them use yours. It could also mean impersonating a health care professional, where someone without a license provides or bills for services or equipment.
Medical providers can also commit health care fraud, by submitting multiple claims for the same service (double billing), or for services the patient never received (phantom billing).
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Other medical provider-committed frauds include unbundling (billing separately for services that should be billed together) and upcoding (billing for a higher-cost service than what was actually received).
The FBI recommends regularly reviewing your explanation of benefits (EOB), checking to make sure the services you actually received match the dates, locations and services listed on your EOB and notifying your health insurance provider if you see any discrepancies.
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How to protect yourself against health care fraud
If you detect discrepancies in your claims, you first want to collect all documentation of the incident, including all communication with both the medical provider and the insurance provider.
Cali could also take the step of letting the insurance provider know about the threats the medical provider made to send the bill to collections — a pressure tactic.
Next, Cali could contact the state licensing board for the medical provider; in Cali’s case that’s a dentist, so she could contact the state dental board and alert them to the actions of the dental office (2). She could also contact her state’s insurance fraud bureau (3).
For help dealing with an insurance provider, you can see if your state operates a Consumer Assistance Program (4).
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Victims of health care fraud can also file a report with the FBI’s Internet Crime Complaint Center.
For a scenario like Cali’s where a provider was found to have made a fraudulent claim by the insurance provider and refuses to provide the patient with an itemized bill, Cali could dispute the debt if the provider did send it to collections.
According to the FTC, you should dispute a mistake with each credit bureau that files the error to avoid damage to your credit score (5).
Failing to provide a bill and telling a patient that a service will be covered by insurance when it is not, could also violate state consumer protections; for example, in New York state, consumers have the legal right to receive a clear explanation of the services being provided and how much these will cost (6).
Though these steps will require your time, they shouldn’t require your wallet.
Article sources
We rely only on vetted sources and credible third-party reporting. For details, see our editorial ethics and guidelines.
FBI (1); ADA (2) National Health Care Anti-Fraud Association (3); Consumer Assistance Program (4); Federal Trade Commission Consumer Advice (5); New York State Education Department (6)
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Rebecca Payne has more than a decade of experience editing and producing both local and national daily newspapers. She's worked on the Toronto Star, the Globe and Mail, Metro, Canada's National Observer, the Virginian-Pilot and Daily Press.
