Spotting Fraud, Waste, and Abuse

Spotting Fraud, Waste, and Abuse

The insurance industry is oft-plagued by suspicious claims, however it’s provider fraud, abuse and waste that need to be heavily focused on.

With $30 billion sacrificed to claims fraud every single year within the insurance arena, 80% of that can be traced back to medical provider fraud by itself. Additionally, the overall cost of healthcare fraud, abuse and waste is roughly $400 billion, which equates to over $45 million lost each hour.

Detecting Suspicious Medical Data

For obvious reasons, medical provider fraud is a major issue for insurers. Unfortunately it can be quite difficult to detect suspicious providers due to a lack of adequate resources and technology. It can also be quite difficult to determine what cases have billing problems due to confusing medical insurance coding and unique treatment protocols. Additionally, many carriers do not have investigative units, making it very difficult to recognize and investigate potential provider fraud and abuse.

Advancements Must be Made

Obviously, the current medical bill review techniques are not adequate to treat these issues. Medical bill reviews only tend to edit to make sure that bills are properly coded; they do not utilize any analytics to look for questionable activity on the part of providers. Because of this, provider fraud, waste and abuse continues to go unnoticed and untreated–resulting in major losses.

Manipulative and Deceptive Provider Behavior

Unfortunately, complicated medical billing allows providers to take advantage patients by manipulating their data and deceiving insurance agencies. These practices include the billing of every single patient for the same treatments, performing/billing for procedures that have nothing to do with the provider, performing/billing for unnecessary procedures or services that were never even provided.

Treating the Issue

Taking a proactive stance and combining it with analytical technology can significantly cut down abuse, fraud and waste; saving your healthcare organization a lot of money every year.

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