Action from Risk Management Company Digital Harbor to Stop Fraud in Healthcare
The loss to the healthcare payer comes in three forms – fraud, abuse, and waste. On an estimate, around $456 is lost every year and authorities think that this can be stopped. Healthcare payers had to shell out $98 billion to Medicaid and Medicare for fraud, abuse, and waste (FAW). This raised their total expenditure by 11% while in the EU, the yearly payout for FAW is €56.5 billion. According to the World Health Organization, the leading cause of spending inefficiency is due to FAW.
Different kinds of fraud
To know the various types of healthcare frauds, we have to understand the way abuse and waste plays a role in depleting the funds of the payer. In many instances, the diversion of funds doesn’t happen due to a primary motivation of criminal intent. On the other hand, fraud is the deception with the intent to collect unauthorized benefits. Look out for the under-mentioned commonly used healthcare fraud cases.
- Billing without providing the service – this is the most common type of fraud. The provider produces bills for services that never happened. Or, it might be medical equipment that the doctor never supplied.
- Multiple doctor visits – this happens when someone is looking for big amounts of a controlled substance. He or she goes “doctor shopping,” visiting many doctors and getting a little from each of them.
- Upcoding – in this case, the bills shown by the healthcare provider is more expensive and complex than the actual. At times, this happens by mistake as when a provider enters the wrong code by mistake. Very often, it is intentional fraudulent action. When a procedure might be performed by simple or expensive equipment and the bill is produced for the expensive one while the actual one used was the inexpensive one.
- Unbundling – this process happens when a set of procedures take place but the billing is done separately for each one. This makes the total bill very much bigger than the actual one. A patient might undergo a panel of blood tests. When the whole panel is billed as one, it works out cheaper than if the tests are billed one by one.
- Listing unnecessary services – when the provider performs unwanted tests on patients it becomes a dangerous fraud. There is a distinct element of danger in performing unneeded tests just to get a bill and reimbursement for the same.
As the leading risk and fraud detection agency, we at digitalharbor provide the latest software for the detection and prevention of fraud. It should be noted that by detecting the fraud in time, the danger to the patient is also prevented. Take the instance of the doctor who advised chemotherapy for patients who were not cancer patients. The doctor made a bundle of money ($17.6 in all) from healthcare payers and endangering the lives of all those patients for whom he had recommended chemotherapy.
Even worse is the case of medical identity theft. The digitization has helped the medical industry stop this to a large extent. Use of CGI ProperPay has helped screen the incidents and isolate the fraud cases.