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While there have been regular reforms – medical billing and coding compliances such as EHR System, CPT coding regimen, and HIPAA compliant medical reporting, auditing programs – for checking this burgeoning problem, yet, insurance carriers are unable to shield themselves completely from this menace. The duality of this menace further compounds the issue:
Duality of Fraud and Abuse of Health Insurance Schemes
Fraud by Beneficiaries of Healthcare Providers Fraud by Healthcare Providers
- Using a member ID card that does not belong to that person
- Billing for services that were not provided
- Adding someone to a policy that is not eligible for coverage
- Duplicate submission of a claim for the same service
- Failing to remove someone from a policy when that person is no longer eligible
- Misrepresenting the service provided
- Doctor Shopping – visiting several doctors to obtain multiple prescriptions
- Upcoding – charging for a more complex or expensive service than was actually provided
- Billing for a covered service when the service actually provided was not covered
But, in the face of radical health care reforms – Affordable Care Organizations, proposed cuts to Medicare, and the negative impact of imminent Sustainable Growth Rate backlash – Federal Government’s Medicare and Medicaid – which account for a major share in the nation’s healthcare insurance scheme – along with major private insurance carriers, have the monumental task of safeguarding against adverse impact of health insurance frauds and abuse including higher premiums, lower benefits, higher taxes and higher copayments.
The scenario warrants these providers to either build or outsource proven anti-fraudulent measures that can ensure a profit-building model through raising premiums or adding new members. Such anti-fraudulent measures assume greater weight when they are faced with the undesirable prospect of erosion of their funds by 10% to frauds and abuse. With historical experience of internal anti-fraudulent measures leaving a lot to be desired for, recourse to proven agencies that have demonstrated optimum efficiency in anti-fraud measures and recovery rate is recommended.
Medicalbillersandcoders.com – having the distinction of being the largest medical billing consortium, and advisory to many insurance carriers – should be of immense help in this regard. With their exposure in billing and coding across specialties and payers, and expertise in all billing issues related to the latest compliances and regulations, their consultancy services can assist in scrutinizing inadvertent billing and book-keeping oversights, and pro-actively minimize compliance exposure by healthcare providers.