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:
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:
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.
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:
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.
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.
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.
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.
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.
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