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 overprescription 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.

2. 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 diagnoses, 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.

3. 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.

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