Combating Healthcare Fraud and Abuse – A Challenging Task for Providers


The inherent nature of Health Insurance is such that it is highly susceptible to fraud and abuse by unscrupulous healthcare providers and beneficiaries. Consequently, there has been an unbridled rate of fraud and abuse amounting to billions of dollars – a reliable statistics puts it around 300 billion dollars, and still counting. Whereas, primarily, it is a staggering erosion of Private and Federal Government’s Health Insurance Funds, it has wider repercussions: payers, employers and patients having to pay higher premiums, lower benefits, higher taxes and higher copayments on account of rising cost of health benefits, necessitated by unethical erosion of healthcare insurance funds.

While there have been regular reforms – medical billing and coding compliances such as EHR System, CPT coding regimen, and HIPAA compliant medical reporting, auditing programs – for checking this burgeoning problem, yet, insurance carriers are unable to shield themselves completely from this menace. The duality of this menace further compounds the issue:

Duality of Fraud and Abuse of Health Insurance Schemes
Fraud by Beneficiaries of Healthcare Providers Fraud by Healthcare Providers

  • Using a member ID card that does not belong to that person
  • Billing for services that were not provided
  • Adding someone to a policy that is not eligible for coverage
  • Duplicate submission of a claim for the same service
  • Failing to remove someone from a policy when that person is no longer eligible
  • Misrepresenting the service provided
  • Doctor Shopping – visiting several doctors to obtain multiple prescriptions
  • Upcoding – charging for a more complex or expensive service than was actually provided
  • Billing for a covered service when the service actually provided was not covered

What is more alarming is that these dual entities have the propensity to collude and operate through an unholy nexus. Faced with such imminent threats, it is high time that health insurance providers implemented an effective program that can detect, investigate, prevent, prosecute, and recover the loss of corporate and customer assets resulting from fraudulent and abusive actions committed by providers, members, groups, brokers, and others. Although RAC audits have been able to recover a substantial amount of fraudulently claimed reimbursements, still, a considerable number of cases find ways to sneak in under their nose; the high cost of appointing Recovery Audit Contractors (RACs) – nearly ¼ of the total reimbursement to be audited for fraudulent realization – is not helping the cause either.

But, in the face of radical health care reforms – Affordable Care Organizations, proposed cuts to Medicare, and the negative impact of imminent Sustainable Growth Rate backlash – Federal Government’s Medicare and Medicaid – which account for a major share in the nation’s healthcare insurance scheme – along with major private insurance carriers, have the monumental task of safeguarding against adverse impact of health insurance frauds and abuse including higher premiums, lower benefits, higher taxes and higher copayments.

The scenario warrants these providers to either build or outsource proven anti-fraudulent measures that can ensure a profit-building model through raising premiums or adding new members. Such anti-fraudulent measures assume greater weight when they are faced with the undesirable prospect of erosion of their funds by 10% to frauds and abuse. With historical experience of internal anti-fraudulent measures leaving a lot to be desired for, recourse to proven agencies that have demonstrated optimum efficiency in anti-fraud measures and recovery rate is recommended. – having the distinction of being the largest medical billing consortium, and advisory to many insurance carriers – should be of immense help in this regard. With their exposure in billing and coding across specialties and payers, and expertise in all billing issues related to the latest compliances and regulations, their consultancy services can assist in scrutinizing inadvertent billing and book-keeping oversights, and pro-actively minimize compliance exposure by healthcare providers.

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