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Most healthcare providers are struggling daily with fraud. Such frauds cost the US healthcare industry over 3 to 15 percent of the total healthcare expenditure in the country. Thus, healthcare fraud prevention is crucial to mitigate the risks associated with it.

Let’s explore the following:

What is healthcare fraud?

Steps to Healthcare Fraud Prevention

Fraud prevention in healthcare is the top priority of medical providers and insurance companies – both are at the receiving end of disadvantages related to fraudulent healthcare activities. The first step is to minimize and remove complexities from medical billing processes.

Understanding Healthcare Fraud and Abuse

Fraud and abuse are most used to describe a variety of reimbursement issues. These issues range from duplication of services and information to not actionable testing. Furthermore, it extends to exaggerated complexity and misinterpretation of services and how all products and services are billed but not provided.

Creating a Strong Compliance Model

Creating a robust healthcare fraud prevention compliance program is vital to prevent fraud and abuse. Furthermore, a compliance program is also a tool to identify fraud.

A robust compliance program includes the following:

  • On-going training and education initiatives for staff
  • A robust process for receiving healthcare fraud prevention reports and complaints
  • Creating procedures that help protect and ensure anonymity and safeguard whistleblowers from retaliation.
  • A complete set of written conduct policies and standards must be put into practice to promote your practice’s commitment to compliance.
  • A complete and proper system must be implemented for responding to healthcare fraud and abuse accusations.
  • Healthcare fraud prevention also necessitates actions against the staff violating compliance laws and policies.

Healthcare fraud prevention becomes incredibly easy with the introduction of compliance programs. Furthermore, an additional factor includes the improvement of a healthcare provider’s medical billing and coding procedures.

Healthcare Fraud Prevention Via Improvements in the Medical Billing Process

Some kinds of medical fraud are found to be intentional, and such deliberate fraud can lead to criminal charges and civil suits. Furthermore, fraud detection also takes a relatively long time; thus, providers face many charges when caught. The common types of medical fraud are classified into the following categories below:

Excessive Billing

Physicians are fully aware of the time needed for diagnosing and treating patients for a particular condition; thus, they can detect excessive billing.

The particular information empowers a group of physicians to identify the ideal number of patients treated for a condition in a day. Upcoding is reporting a higher level of service than what can be supported.

Insurance companies pay more for treating severe conditions, and upcoding for such instances helps raise a practice’s revenue. The OIG (Office of Inspector General) holds a list of codes for checking upcoding. They may conduct a full audit of a healthcare practice. Such audits check if the number of claims in submission is more than expected. Finally, physicians must avoid upcoding as a practice, as such practices can be heavily fined if and when OIC finds intentional upcoding of claims.

Inadequate or Falsified Medical Documentation

Different types of medical claims are put to submission without medical records. Such instances allow physicians to increase their reimbursements by manipulating claims without even triggering an audit.
Nonetheless, omission of critical information from claims to cover errors and altering medical records to increase revenue intentionally are illegal activities and, thus, should be avoided.

Providing Additional Services to Patients

Another common type of medical fraud is charging the insurance provider for more services than patients need. Such types of fraud include offering unnecessary services and even services that were never even performed for the patient. It is sometimes difficult to detect intentional charging for excessive services; this results from following poor billing processes. For healthcare fraud prevention, medical practices must put efficient operations in place that successfully capture the charge of each service.

Final Words for Healthcare Fraud Prevention

Detection and fraud prevention is a multifaceted and continuing process that requires a multidimensional approach. Keeping caution, remaining hands-on, and being informed about the recent fraud detection techniques and the best practice involved is vital for protecting your healthcare practice. Furthermore, ensuring healthcare fraud prevention also protects your patients and financial resources from the devastating effects of healthcare fraud.

Frequently Asked Questions

Fraud prevention is about establishing countermeasures for mitigating the impact of fraudulent activities on your business operations. At the same time, fraud detection is the first step in identifying risks.

Blockchain technology and Artificial intelligence are both helpful in preventing fraud in medical billing. For instance, ML (machine learning) algorithms can analyze massive chunks of data and detect patterns in addition to anomalies that indicate any cases of fraudulent activities.

The A/R (accounts receivable) follow-up team handles the denied claims and efficiently re-opens them to receive maximum reimbursements from insurance providers.