3 Ways to Prevent Medicare Fraud, Waste and Abuse

Approaching your Medicare fraud, abuse, and waste prevention comprehensively as opposed to doing it in pieces is the best way to tackle this growing issue. There are three pieces to this puzzle that must be tackled in order to increase recoveries: Clinical audits, appropriate technology, and investigative abilities.

The Most Common Kinds of Exploitation

Fraud, waste and abuse are the three categories of improper payments within government healthcare assistance programs such as Medicare and Medicaid. While comprehensive payment integrity programs are meant to address these misuses, they still miss some areas of fraudulence or wasteful activity, resulting in major losses. Some of the commonly overlooked abuses include the over prescription of opioids, failure to report offending providers to the state and allowing it to continue, and the failure to recover millions in overpayments.

In order to more effectively fight waste, fraud and abuse, you must ensure your solution contains the following key components:

  1. Technology

In order to be compliant with preventative regulations, organizations must align large amounts of data. Technology assists with this by taking this data and identifying any outliers and patterns far more efficiently than any human can. With improper payments on the rise, there have been significant reform measures implemented to help stop it; applying notable pressure to eliminate fraud as quickly as possible.

Technological solutions can easily shift the tides, especially when utilized alongside larger, more integrative payment systems.

  1. Clinical Audits

The second facet of prevention is the ability to carry out clinical audits. This allows for the review of claims that are flagged as potential waste, fraud, or abuse. Clinical audits will help determine if a diagnosis, medication, the amount of time spent with the patient, and additional details should be further investigated or not. Additionally, clinical audits connect real-time data between payers and providers.

  1. Investigative Capabilities

It’s important to arm yourself against non-compliance via the ability to investigate efficiently. In the event that fraud is suspected, investigative capabilities allow for the immediate reporting of fraud to appropriate authorities, while also providing evidence that can support and protect health payers. Should a claim move forward to court, the documentation and evidence from the investigation is invaluable.

Due to the vast amount of data collected in the healthcare industry, it provides a terrific opportunity to recognize trends in abuse, waste and fraud and to further prevent it in the future.

What You Should Know About Medical Fraud, Waste and Abuse

While fraud is technically different from waste and abuse, data shows that technological solutions fail to fully tackle any of these issues. The losses are in the billions, and the only way to solve it is through system visibility and proactive methodology.

How to Fix It

In order to fully eliminate the overpayment crisis, it’s imperative that health organizations take a complete look into the issues that have not yet been tackled. With losses totaling $36 Billion plus per year, this is an issue that must be resolved ASAP. A solid solution must be able to quickly identify where the leakage is coming from at your organization. A combination of the following knowledge can help you combat fraud, waste and abuse:


Wasteful spending can easily amount to one-third to one-half of healthcare spending. Administrative complexities are partially responsible for the issue, so it makes sense that increased efficiency can dramatically impact overall wastefulness. If you’re not focused on achieving efficiency, you will always struggle with containing wastefulness.

Waste and Abuse Outweigh Fraud

Fraud is when someone is purposely playing the system in order to benefit from it. However, fraud is quite rare and only makes up about 7% of spending when combined with healthcare abuse. For obvious reasons, the fear of fraud can be significant, which can lead to overinvesting in technology that does not completely encapsulate all of the overspending issues–especially waste.

Partnerships Help

Patient-payer partnerships open the door for further improvements in safety, communication, and the reduction of unnecessary costs. Collaboration allows for investment from all parties involved in preventing fraud, waste and abuse.

Shared Reporting Should Be Ongoing

Healthcare organizations should take regular looks at their metrics, while also sharing their findings with all related parties–including providers, staff and vendors. Openly shared information is beneficial to everyone seeking to reform fraud, waste and abuse within healthcare organizations.

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