Easy Steps to Remain Positive on Healthcare Fraud Detection and Prevention

Healthcare spending via Medicaid and Medicare services has reportedly increased by 4.6% to a little less than $3.5 trillion. Due to the high enrollment, Medicare growth at 7.4% is expected to exceed that of Medicaid at 5.5% and private health insurance at 4.8%. But, what about health insurance fraud? This thought does not occur to most of the people because they do not involve in fraudulent practices. But, there are some who do and this is where fraud detection and prevention methods come in. 

Important to stop loss through fraud

Rather than lose hundreds if not thousands of millions of dollars to fraud, the onus must remain on using intelligent methods to detect and stop healthcare fraud. One leading source is Digital Harbor. We are the pioneers in fraud detection and risk management for healthcare systems. Healthcare fraud is the instance when an insured person or a healthcare provider gives false information with the intention of benefiting from this action. This includes unauthorized benefits to the policyholder through false information. The person involved may be a third person also.

Employees are able to see both sides of this scenario as employees being tricked by fraudsters or exploiting the situation and raking in unwarranted benefits. Since both cases are detrimental to the well being of the healthcare industry, it is imperative that one takes the proper action when one sees such an occurrence. 

Definition of fraud

The term ‘insured members’ covers all the employees or all the members of the family. This widens the scope of the term fraud there is a whole load of people who could be involved. In order to understand the meaning of the word ‘fraud’, one must keep in mind that all these people could be involved. You are said to indulge in fraud when you do one of these things:

  • Use the benefits of health insurance to pay for medicines not prescribed by your doctor.
  • Not removing a person who is no longer eligible for benefits.
  • Using an accident done on purpose to receive reimbursement and medication.
  • Using identity and insurance cards from someone else to get healthcare services.
  • Give false information to add an ineligible person to the insurance policy.
  • Get several prescriptions by visiting many doctors.
  • Make an exaggerated claim.

As a service provider, we digital harbor have several years of experience in this line. We are the pioneers of Know Your Client (KYC) platform for banking services and so we have enough experience in risk management and fraud detection. 

Impact of healthcare fraud on your business

The first and biggest impact could be reduced benefits that the employers offer to their employers. As the insurance premiums continue to grow, the employers are left with no option but to cut back on the benefits they can afford to give to their employees. The insurance premiums rise because the insurance companies and more money to detect and prevent insurance fraud. An insurance cover is not within the affordable range any longer. Another bad impact is that the copays and deductibles become higher and this can impact the paying capacity of the employee badly.

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