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Recognition Of Fraud And Defining Risk Management In Health Care Services

Before one defines fraud in health care services, it is important to make the distinction between waste and abuse. Waste is the overuse of any material while abuse is unknowing use of services or material where it has no use. Fraud is different from these in that it is the willful effort to get benefitted from the healthcare system by misrepresenting facts.

 Look at the various types of fraud

We are digital harbor, the provider of end-to-end operational intelligence suite to detect fraud, monitor, assess, and investigate the fraud and the risk involved. Here we take a look at the various types of fraud involved in the healthcare system.

 Fraud involving billing

This kind of fraud is not so prevalent in big hospitals where the system of billing and supply of healthcare is systemized. In small clinics and hospitals that use paper-based billing system, the existence of fraud is more. An example of such an occurrence is the case where the hospital bills the patients for healthcare service given by a highly qualified physician while the work was actually performed by a lower-ranked physician. This is the case where the work of the doctor is done by the nurse. The bill is for the doctor’s rate and the nurse might not even be qualified to do the job. In a similar situation, the practice of up coding is used to charge for items that were not given.

 Fraud involving the doctor

Many unethical doctors augment their revenues by using the complexity of the diagnosing system. The simplest case of fraud is where the doctor insists that a certain procedure is needed in a case where it wasn’t. For instance, a doctor might insist that surgery is needed while the reality is that you could cure the ailment through the use of drugs alone. The insurance company has to then foot the bill. Of course, the insurance companies insist on a concurrent clinical review that is of acceptable standards of level-of-care.

 Fraud involving the patient

This type of fraud doesn’t involve collaboration between the medical service providers and the patient. Usually, it is committed by patients seeking drugs and involves the misuse of insurance ID cards. For example, if a patient fakes back injury, he will become eligible for disability pension. In these cases, we will conduct investigations on our own to make sure the facts given by the patient is correct.

 Fraud involving drugs

Stealing of drugs by workers is sometimes present because they can cover the theft by using their position. They get subsidized prescription drugs and then resell them on the black market for a higher price.

Being the maker of pioneering technologies such as Know Your Customer and Know Your Provider platforms in the USA, dharbor recognizes the challenges involved. We have given services that resulted in savings of more than $500 million for our customers in the healthcare sector.

By detecting and preventing fraud, the healthcare system stands to gain plenty. It is up to the employees to report fraud either directly or by giving an anonymous tip. By keeping up the practice of detecting and preventing fraud, it is possible to have a system that is totally free of fraud.

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