PREVENTION OF HEALTHCARE FRAUD, WASTE AND ABUSE

By Internal Eseo - April 01, 2018




Big data has immensely contributed towards the healthcare industry and making it more efficient than before. However, the health insurers are under the constant threat to deal with medical abuse, fraud, and waste. Big losses could occur due to fraud, waste, and abuse. FWA in healthcare could be due to an error in billing, inefficiencies that lead to wasteful diagnostic tests, to false claims that lead to improper payments. FWA training can occur irrespective of the size of a medical practitioner. However, the negative impact on the industry has been enormous. If the figures are referred to the losses due to FWA it is much greater than prevalent in any other industry. What makes the situation more grave is that only minutely the losses are recovered every year. Thus looking at the bigger picture not only the insurer who pays the claim but also the consumer has to bear the expensive healthcare costs.

A complex coding and billing health care system:

Not all the FWA cases are intentional a major number of cases are due to inefficiency and unintentional and result in multiple tests and incorrect billing. One of the major factors that contribute towards this is the complex billing and reimbursement system that the healthcare providers will have to rectify. This industry makes the payment primarily based on the codes that specify the procedure of treatment. The latest and modified versions of codes are to be implied to detect any presence of FWA. The main issue is the presence of wide variety of codes that are big and often lead coding errors. Lack of experience with the structured codes, lack of training and over exhausted staff also contribute towards an error in reimbursement claims that are to be borne by the insurance companies.

The above was the error that was unintentional but the error in simple billing and coding by manipulating the data that results in overbilling and overpayments to commit a fraud is another culprit.

Medical fraud waste and abuse training are essential to stop the malpractice in the industry and try to save as much as possible. The few common frauds that one can detect with the help of FWA training are as follows:

1] Billing for the services that have not been rendered
2] Billing for more expensive services than the rendered ones or upcoming
3] Unbundling of services
4] Performing the services that were not essential as per medical science

Medical fraud, waste, and abuse prevention training aim to reduce the unnecessary expenditure that poses a major threat to the health insurance business. Only through rigorous FWA training these anomalous transactions can be identified and rectified.

The training can help in saving the time and resources during the process. Benchmark needs to be fixed for correct identification of the FWA. This HIPAA training helps to identify the unethical practices industry and detect FWA and also prevent it.








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