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FRAUD & ABUSE

FRAUD & ABUSE. PROVIDERS PERSPECTIVE. PROVIDERS PERSPECTIVE. Examples of Fraud by Providers Billing for services that were not provided Performing medically unnecessary services Altering claim forms, medical documentation , etc. Duplicate billing (deliberate)

daniel-harrell
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FRAUD & ABUSE

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  1. FRAUD & ABUSE PROVIDERS PERSPECTIVE

  2. PROVIDERS PERSPECTIVE Examples of Fraud by Providers • Billing for services that were not provided • Performing medically unnecessary services • Altering claim forms, medical documentation, etc. • Duplicate billing (deliberate) • Exorbitant or “exploding” charges • Billing for a service that costs more. • Offering, or receiving a kickback for referral of patients in exchange for other services.

  3. PROVIDERS PERSPECTIVE (Contd) • Misrepresenting non-covered services as medically necessary, e.g., billing “nose jobs” as deviated-septum repairs, routine foot care as diabetic foot care • Using another person’s ID card to obtain care services

  4. PROVIDERS PERSPECTIVE Prescription / Drug Fraud • Pharmacy dispensing a generic but billing for a brand • Patient selling drugs back to the pharmacy for pharmacy to re-sell • Prescription forging/altering.

  5. PROVIDERS PERSPECTIVE Prescription / Drug Fraud (contd) • Incentives to physicians to prescribe medically unnecessary drugs/brand names (manufacturer) • Counterfeit drugs through black/grey market (wholesaler)

  6. Examples of Abuse • Charging in excess for services/supplies beyond tariff. • Providing medically unnecessary services • Providing services that do not meet professionally recognized standards

  7. Difference between Fraud & Abuse • Fraud requires evidence of intent to defraud, i.e., acts were committed knowingly, willfully and intentionally. • Abusive billing practices may not result from “intent” or it may be impossible to prove that the intent to defraud existed; however under certain circumstances, these types of practices may develop into fraud

  8. What Insurance Cos expect from Providers • Providers should • Not charges more than tariff. • Maintain proper records of patients for future reference. • Not advice unnecessary test or un-indicated tests. • Do not issue wrong medical history or modify history after the claim. • Cooperate with Ins Cos/ TPA to give details of any patients in case of deficiencies. • Not exploit patients • Not sell Medicines/ Implant/ materials without supporting invoices.

  9. What Provider Expects from Ins. Cos/ TPA • Inform patients(proposers) about • diseases covered & excluded before policy is issued. • maximum amount payable for a particular disease. • Co-payment if any payable. • Don'ts • demand unnecessary papers from hospital not related to disease

  10. What Hospital Expects from Ins. Cos/ TPA • Don'ts(contd) • Harass doctors during busy schedule • DO’s • Quick response in case of cashless admission • Releasing promised amount within 15-30 days • Separate grievance cell • Skilled & qualified processing team • Update about any change in policy conditions to the hospitals.

  11. What Hospital Can Do to avoid Frauds/ Abuses • Corporate hospitals can keep check on individual doctors involved in fraudulent practice. • Small nursing homes/ Hospitals- difficult but, if anyone notices should be reported to local association.

  12. What Ins. Co/ TPA Can Do to avoid Frauds/ Abuses • Collect Data of doctor/ hospital involved in such practice and share. • Appoint spot investigators for suspicious areas/ hospital/ doctors(during admission). • Investigation in Reimbursement claims • Decide tariff of various ailments with related complications considering • location of hospital • Status of doctor • No of beds & facilities(Single or Multi Specialty) • Data from various hospitals

  13. What Ins. Co/ TPA Can Do to avoid Frauds/ Abuses • Why Preferred Provider Network(PPN) did not work • Non appealing • Advantage for small town & peripheral hospitals • No proper communication to patients • Conditions

  14. What Ins. Co/ TPA & Providers can do to avoid Frauds/ Abuses • Involve local association to decide tariff for various ailments. • Printing of Charges(in the policy) of common ailments & its limits in various hospital( A, B, C D category). • Punitive measures against those hospitals & doctors involved in fraud & abuse.( Should be printed in policy). • Blacklist hospital/doctors & Insurance agents involved • Common policy conditions & claim forms.

  15. THANK YOU

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