Cleveland - Medical Mutual of Ohio's financial investigations unit reclaimed $5.4 million in fraudulent claims in 2005, the largest amount in company history.Calling it perhaps the costliest of all crimes, the National Health Care Anti-Fraud Association (NHCAA) estimates more than $100 million is lost each and every day to health insurance fraud.

Everyone pays for health insurance fraud, notes John Shoemaker, financial investigations unit manager at Medical Mutual. "The criminals behind these acts are actually stealing right out of the pockets of the health insurance customer and, in the end, the cost of fraud is passed on to all of us."

According to the NHCAA, health insurance fraud is responsible for upwards of 5% of the total cost of all health care in the United States annually. "Our mission is to simply try to help hold the line against higher health care costs," said Shoemaker.

On an average, Shoemaker and his highly trained staff investigate 120 cases of potential fraud per year and in the past two decades have produced more than 600 indictments. Since 2003, Medical Mutual has reclaimed nearly $14 million in fraudulent claims. In 2004, $4.5 million was recovered.

Shoemaker says the digital age is playing a huge part in nabbing health insurance fraud artists. In 2003, Medical Mutual purchased the ViPS STARSentinel software from Emdeon Business Services. As an early-warning anti-fraud detection system, STARSentinel monitors claims for signs of fraudulent activity. "This software helps us focus efforts on cases most likely to have fraud," said Shoemaker. "This year, the company has nearly five and a half million reasons to believe the staff and software are working well together."

Source: Medical Mutual of Ohio

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