Dealing with the Impact of Health Insurance Fraud on the Health Care System

Fraud of any form costs the health insurance payer something more than money alone. A huge effort has to go into the Health System to investigate whether the incident was accidental or done on purpose and how it occurred.

 Fraud in the Health System

It takes someone to commit the fraudulent act. It affects the cost and resources and impacts the way people react to the system. Some people begin to lose faith in the system while others choose the way of committing fraud to pay their bills. It is essential to detect fraud in time so that preventive action can be taken. One of the leading service providers in fraud and risk detection, dharbor has been at the forefront of providing care for those who need it. We are the pioneers of several technologies in use today such as Know Your Provider and Know Your Customer.

People involved in fraud

To prevent abuse to the system, it is necessary to know who commits these criminal activities. We use advanced software that is integrated with your business management software for seamless deployment to detect fraud. Here is the list of possibilities where fraud can happen:

  • Patients – They can provide fraudulent sickness certificates, commit fraud in getting the prescription, and try to get out of paying the medical charges.
  • Medical professionals – Fraud concerning the prescription is done by the pharmacists. Also, there is error or fraud in the payment for the facility services, consultations, and medical services.
  • Contractors – Insurance fraud can occur and error and fraud concerning long-term care or community-based services, and child care.

Knowing about different types of health insurance fraud

Detecting the health insurance frauds to mitigate the risk is the work we at Digital Harbor do. Having worked with Government Intelligence agencies and some of the biggest financial institutions in the U.S., we help your organization become capable of handling all risks effectively. One must become familiar with different risks in order to tackle them in a capable way.

  • Doing unnecessary surgeries and giving unwanted treatments to make insurance payments higher.
  • Use of false records to account for the need for medical action.
  • Doing upcoding to make the bill higher by showing expensive procedures and use of costly equipment when the actual ones were not that expensive.
  • Showing uncovered treatments.
  • Crating bills for patients more than their deductible amounts or copay.
  • Accepting kickbacks for referring patients.
  • Padding claims and showing services that were not used.
  • Unbundling is billing a group item as individual items to inflate the cost.
  • Waiving costs and billing them to the insurer.

Understand the costs of medical fraud

The losses to the health system is rising due to the fraud payments so that it had become $487 billion by 2011. This represents the hidden costs that everyone bears when they make payments for their health care.

Load on the health care system

One of the main issues was that of the doctors ordering unnecessary procedures if they profited from it. A survey of physicians showed that a good part of the medical care including one-fifth of the prescriptions, about one-quarter of the tests, and one-tenth of the procedures was unnecessary. Digital Harbor is helping deal with cost-reduction and fraud at all levels.

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