Detecting Healthcare Fraud, Waste, and Abuse
A key step in the fight against Fraud Waste and Abuse (FWA) in healthcare is the detection of an aberrancy of significance--some atypical pattern that you would not normally expect to see within a batch of legitimate claims. Although isolated errors are consistently made in claims submission, tools which can help see beyond them and isolate patterns that are suspicious for fraud on a grand scale, or at least waste or abuse of a significant scope, can prove valuable.
Combating Overutilization of Healthcare Resources
Overutilization in Healthcare is a problem which has been estimated to cost in the range of hundreds of billions of US dollars every year. Despite historically spending more than double per person on healthcare than the average developed country, our outcomes have not been significantly better. To improve, specialty organizations publish clinical quality initiatives and practice guidelines that support consistent, focused, evidence-based care.
Keeping a watchful eye on telehealth claims
Telemedicine has grown significantly in recent years due to new technologies and consumer demand. According to an April 2017 study by Grand View Research, the telemedicine market is expected to grow to $113.1 billion by 2025 with an estimated compound annual growth rate (CAGR) of 18.8%. An anticipated 7 million patients in the U.S. will access telemedicine services in 2018, a sharp increase from 350,000 in 2013. Payer reimbursement policies, on the other hand, are slow to adapt to the new services.
When fraud causes patient harm, and how to find it before it does
It’s been called the most sinister, the most egregious, the worst kind of health care fraud – providers performing medically unnecessary procedures. When this type of fraud makes the headlines, it is indeed sensational.
Healthcare Fraud and Abuse Schemes – How to Spot the Patterns
Before the use of electronic claim submissions and EHRs, the only option payers had to detect fraud, waste and abuse was “foot-on-the-ground” auditing at provider sites. Even today many payers still rely on this manual process. These types of audits are time consuming, expensive and performed after claims have already been paid. Technological advances have radically changed FWA pattern recognition. Today, statistical sampling based physical claim audits aren’t necessary when payers can automate testing 100% of claims.