The National Health Care Anti-Fraud Association estimates that healthcare fraud costs the nation about $68 billion annually. That’s about 3 percent of the nation’s $2.26 trillion in healthcare spending. However, many believe that this amount is actually closer to $900 billion.  This huge amount of healthcare fraud exploits the most vulnerable of our population. Organizations involved in healthcare service payment and reimbursement should have a fraud and abuse management system in place to combat the ever-growing problem.

fraud detectionFake Fraud Schemes

Most physicians strive to provide exceptional service, work ethically, and render quality care. Dishonest healthcare providers exploit the system for their own personal gain, which has propelled the need to set laws in place for fraud detection and ensure the best possible care.  Many fraud schemes depend on the submission of fake insurance claims. Not only do these fake claims produce a phony diagnosis that can wind up on a patient’s medical record, but they can also result in untold pain and suffering by those who endure the needless financial hardship these claims can produce.

Unscrupulous and  Phony Healthcare Providers

Healthcare fraud can be carried out by dishonest healthcare providers or those who are just pretending to be healthcare providers.  The billing of services not rendered, billing for expensive services, erroneous diagnosis for the justification of unnecessary surgeries or other procedures, and performing unnecessary procedures are just a few examples of how these unscrupulous actors take advantage of the system and patients.

Unnecessary Procedures and Prescriptions

Unnecessary procedures can put a patient’s health and life in danger. These medical procedures can have devastating side-effects and put patients at risk of long-term complications. Many fraudulent procedures are conducted for one purpose: large insurance payouts from insurance providers, including Medicaid and Medicare. In the prescription drug arena, a fraudster may scheme with a pharmacist to add pricey medications to a prescription claim without the knowledge or consent of a patient. This false claim is then submitted for reimbursements to the insurer.

Waste and Abuse

Fraud is only part of the story.  The healthcare industry also must be diligent about keeping a close watch on waste and abuse. Waste can be the overuse of services or mistakes that result in unnecessary costs to the healthcare system. Abuse occurs when medical practices aren’t adhered to, which lead to needless treatments and expenses.  Although not necessarily a criminal offense, abuse can be the misuse of resources and materials to gain a profit.

A Fraud Detection System

The prevention of healthcare crimes begins with implementing fraud and abuse management that will provide ultimate fraud, waste and abuse detection. Fraud detection software is imperative for claim processing. The reduction of loss is a high priority in the healthcare system. The high costs that come with fraud can be alleviated by the proper healthcare fraud software system in place. Too many businesses wait until after fraud is committed to implementing a fraud detection system. With medical fraud software, a medical claim fraud investigator can easily examine the issue and help a business and patients move forward. A solid system will take the leg work out of fraud detection and the issue can be remedied immediately.

With the right tools in place, fraud detection can be a simple process. A professional system can assist healthcare providers with making quick decisions to increase the satisfaction of their clients, and in turn, cut back on high costs and losses. The goal for medical professionals can be prevention rather than cleaning up a fraudulent mess.

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