For years, substantial resources have been directed on the pretext of preventing fraud by insurance companies, regulators, law enforcement agencies and legislators. But despite these efforts, the relationship seems to grow on the annual estimate based on the fact that the problem has been and continues to thrive.
This might suggest that health care fraud can be stopped at epidemic proportions as our health care system with health professionals concerned, who will stop at nothing to make money? I thinknot.
In my experience, more than two decades working with insurers, suggests that law enforcement officers, regulators and health professionals that the majority of healthcare providers are honest, ethical, and strive to do the right thing!
In addition, my experience has given me the opportunity to see the problem of fraud by both parties, provided that the execution and the provider. Viewed from two points of view, it is easy to see that our problem of health care fraud is caused by a number of factors,including:
1. Inadequate training for healthcare providers, compared with standard coding and payer.
2. Deviant producer.
3. Inadequate training for claims handlers and investigators claims on coding and provider standards.
4. Inept management of claims and investigations requested by insurers for payment of debts.
5. Lack of communication from insurer to provider, what is required.
6. Lack of reliable training for law enforcement investigationsHealth fraud - from identification to law enforcement.
7. Tag-a-long investigators looking for organizational statistics so that the inefficient use of resources of law enforcement authorities.
8. The lack of interest or commitment by prosecutors - big cases big problems, little cases little problems.
9. Lack of accountability for all segments of the health delivery system - suppliers, customers, regulators and guarantors.
Insurers, the most important journalists and the victims of fraud, showing thatall policyholders pay for the fraud in the form of higher premiums. According to the National Insurance Crime Bureau, the average American household will pay $ 200 more each year in premiums for the memories of fraud.
Insurers are very aggressive in reporting the problem has revealed how much the estimates of double-digit percentages of their applications, fraudulent, lost, and billions of dollars annually because of fraud. These reports and evaluations weigh in the minds ofState regulation for insurance, if they allow insurers to increase premiums.
Basically, what my insurers and others when you show their estimates of the frequency and cost of health care fraud, a provider of billing for services not rendered, billing for services that are inferior and / or billing unnecessary services, the nature of services rendered incorrectly, billing for services that the service actually wrong ...
The radical naturethe attention of healthcare providers are becoming more and more, even when they are engaged in fraudulent activities carried out by insurers in the test after the payment is unprecedented, and can range from the ability of our healthcare providers to do what is best to take - and the best people! It is a pity that today, healthcare providers can spend more time documenting and defending their services for a variety of sources, insurers, regulators and law enforcement, then they do on health benefits,Patients.
Health care fraud is a crime that must be dealt with swiftly, responsibly and strong! But healthcare fraud should not be used as a vehicle for one to prosper at the expense of another. Insurers are in business to make money, and doing so just to make money - lots of money! This money comes from premiums from the sale of the policy for consumers in search of protection from future (subject unknown) losses.
Many insurers are able to limit theirHealth potential for exposure, such as the ability to ensure "that the doctor they see, such as treatment services can get to say, do, and how much will be paid for services.
In addition, insurers may restrict payment arbitrarily denying health care claims reported by health care professionals to maintain health services illegal and said that the benefits were fraudulent. Many insurance claims behavioral assessments, as reported in the determinationIf medical care were provided by the supplier always the case and / or reasonable (UCR). I remember that by definition, "Fraud is the knowledge and intentional deception or misrepresentation with the intention of an unauthorized payment received."
Not such an assessment would not be taken into account an assessment of fraud? E 'presumably for the purpose of determining happen if the doctor the type of services provided, and evil, ieFraud.
Unfortunately it seems that the UCR Rating little to do with the actual fight against fraud, but they have to do with controlling costs and improving the bottom line for insurers. These assessments are not generally indicated that the physician has not submitted the reports, the services, but the subjective opinions of consultants, providers report that they see themselves as a rule for patients. In several cases, the insurer can mitigate the billing of health care provider with UCRRatings - not because the assessments were accurate, but because the doctor did not defend the knowledge and resources needed.
The effectiveness of these assessments as a means to combat fraud, is questionable and can not exist.
Check with the regulatory authority of the State to determine and health insurances to determine if insurers get their assessments UCR to them for investigation of fraud, and if so, ask him how many. Ask your local lawsPerformers, like many cases they investigate or prosecute, based on evaluations UCR.
, Ask your insurance company, which include the estimated percentage of losses due to fraud, health care relationships UCR. And why, ask your insurer, with their duty and ability to examine all applications are not able to do a better job to avoid paying for fraudulent claims.
And 'interesting to note that after the late 1980s, health professionals have a coding standard. This system, known as flowProcedural Terminology (CPT), is used by suppliers to be given to the report and bill for health care for patients.
CPT was promulgated by the American Medical Association (AMA), so that all health workers, regardless of discipline could only talk about their services and be compensated for their services.
CPT, although has been around for decades, there is no standard for education and training of health workers for proper use of the code or requireInsurance for what the codes mean. This can lead to a systemic problem in our health system is a necessary contradiction between our health care providers and payers of health care, based on an "attack and defense" of the billing code and create the documentation treatment.
Whether dealing with the codes, ie. To get one for reporting purposes of clearing services, and the other to determine what they will pay.
It should be clear from the annual reports, ifknow that our healthcare fraud can not be solved only with the accumulation of large amounts of resources to tackle the problem, that consortia to share information and research the problem, or the introduction of additional laws or regulations of political Stumping for reuse - Choice. The investigation to combat health care, in order to prosecute the offender is necessary. But also needed is a process of compulsory education for our suppliers, insurers andInvestigators to combat health fraud.
The health problem of fraud is too complex to be fought by the few. Health Care Fraud is a problem that requires more involvement of the principles of our health care system, increasing the likelihood that our success in tackling this costly problem will be exacerbated with identifiable and verifiable.
Health care fraud is the reading of a problem - just the news but this is a problem that can and should be treated with success. Thiswill only happen if we, our anti-fraud team is totally responsible and includes the active participation of healthcare providers.
There is no stronger voice for health care fraud, then, that honest and ethical providers of health - from the way they are also consumers of insurance and health care and a portion of the audience award. Most health care providers on fraud and those who do not want to do more and to watch out of business. Butcurrent fight against fraud Arena has health care providers - even the honest and law-honest ones, as opposed insurers and others.
Health professionals who do not have to engage in fraudulent activities to endure aggressive and invasive meetings with insurers that are paid for legal services provided. This process has a counterproductive effect on our overall success in the fight against healthcare fraud.
Health workers can not engage in fraudulent activity may haveInformation and knowledge that could be useful in supporting the fighters health care fraud. These players could possibly help from street level on the identification of providers of health care fraud cases.
Moreover, healthcare providers can not be involved in fraudulent activities to support the fighters with fraud, establishing evidence for the prosecution of fraud and support. But with the current adversarial system, health service providers, whose duties are not fraudulentActivity may have neither the ability nor the will to support the fighters of fraud, as financial contributors for their mere existence to fight.
Perhaps it is time for the various disciplines of health and health care associations formed an alliance to become the supplier, the arm action to work closely with law enforcement to attack the insurance and the labor healthcare fraud, as well as the insurance industry claims to do. And, just maybe, with such an alliance, there have been anBecause of the annual estimates of costs for health care fraud Decline - now you go, depending on the source, from $ 20 to $ 160 billion.
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