In the US, providers are struggling daily basis with healthcare frauds. These frauds generally cost the healthcare industry 3 to 15 percent of the total expenditure in the United States hence healthcare fraud and abuse must be critical.
What are healthcare fraud and abuse?
Generally, fraud and abuse are referred to describe a range of reimbursement issues. These issues are ranging from duplicated services and informational but not actionable testing to exaggerated complexity and misrepresented services and all how services or products billed but not provided or supplied.
However, factual misrepresentation includes exaggerated complexity, misrepresented services, and services or products billed but not provided or supplied, and the submission of a financial claim for a service or products that did not use.
Developing a strong compliance
Developing a strong compliance program is key to preventing healthcare fraud and abuse activities hence compliance program is useful to identify and prevent healthcare fraud.
Compliance program includes:
- Continuous education and training for staff.
- A set process to receive healthcare fraud reports and complaints and the development of procedures to protect anonymity and whistleblowers from retaliation
- Written conduct standards and policies must be followed that promote the hospital’s commitment to compliance (e.g., by including compliance adherence as part of staff evaluations) and cater to potential fraud like financial relationships with other providers and claims management.
- A proper system must be established to respond to healthcare fraud and abuse accusations and appropriate disciplinary actions against staff who violate compliance policies and laws.
Healthcare fraud and abuse prevention can be easily reduced via compliance programs, there is one more factor which includes improvement of provider’s medical billing and coding processes.
Avoid healthcare fraud by improving the medical billing process
It is observed that some types of medical fraud are intentional. This intentional fraud can result in civil suits and criminal charges. Moreover, it takes a long time to detect frauds so, healthcare providers often face many charges once caught.
Most types of common medical fraud may be classified into the following categories:
Physician groups know the time required to diagnose and treat patients for a particular condition hence they capable of detecting excessive billing.
This information enables a group of the physician to identify a practice can treat a possible number of patients in a day.
Reporting a higher level of service than what is supported in the dictation (Upcoding)
As insurers pay more money for serious conditions hence upcoding helps to raise a practice’s revenue. The Office of Inspector General (OIG) has a list of codes for upcoding and it may conduct a full audit of practice. The audit is carried out to check if the number of claims submitted is more with these codes than expected. Hence physicians must avoid upcoding as practice can be heavily fined if the OIG determines intentionally upcoding claims.
Improper Medical Documentation
Reasons for Improper Medical Documentation is that many types of claims may be submitted without medical records which allows healthcare providers to increase their reimbursements by manipulating claims without triggering an audit. However, altering medical records to increase revenue and intentionally omit critical information from a claim to cover errors in a patient’s treatment are illegal activities hence physicians should avoid both.
Provide excessive services to patients
A common type of medical fraud is charging the insurer for more services than the patient needs.
This type of fraud includes providing unnecessary services and charging for services that were never even performed.
It is often difficult to detect the intentional charging for excessive services as the result of poor billing practices.
To avoid such kind of fraud healthcare facilities should have processes in place that effectively capture the charge for each service, although this isn’t always the case.
Are you looking to avoid such frauds? We can help you to avoid medical billing errors. We are HIPAA compliant and a national leader in medical billing and coding.