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This document explores the multifaceted issues of fraud and abuse from the provider's perspective in healthcare. It outlines common fraudulent practices such as billing for unprovided services, unnecessary treatments, and altering medical documentation. The text distinguishes between fraud (intent to deceive) and abuse (potentially unintentional overcharging). It also outlines expectations from insurance companies, providers, and hospitals to avoid fraudulent activities. The importance of cooperation and proper record-keeping is emphasized to prevent fraud and maintain integrity in healthcare services.
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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) • 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.
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
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.
PROVIDERS PERSPECTIVE Prescription / Drug Fraud (contd) • Incentives to physicians to prescribe medically unnecessary drugs/brand names (manufacturer) • Counterfeit drugs through black/grey market (wholesaler)
Examples of Abuse • Charging in excess for services/supplies beyond tariff. • Providing medically unnecessary services • Providing services that do not meet professionally recognized standards
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
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.
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
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.
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.
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
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
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.
