Healthcare fraud is an alarming and rapidly growing problem in the United States. Fraud in the healthcare and medical sector affects the US economy, and it was estimated that in 2020 it cost an estimated $170 billion dollars. This type of fraud affects taxpayers and can harm the reputation of healthcare providers, hospitals, and the entire healthcare system. Health 2.0 Conference raised concerns about these healthcare frauds and discussed a few quick ways to prevent them in 2023.
Different Types Of Healthcare Fraud, Discussed At The Health 2.0 Conference
Billing Fraud
One of the most standard types of healthcare fraud is billing for services that are not provided or misrepresenting services provided to get more money. These frauds include providing medically unnecessary services, a different type of service than billed, and upcoding or charging more than necessary for services or items, shared Health 2.0 Conference. This billing fraud occurs in hospitals, outpatient centers, nursing homes, doctors’ offices, clinics, pharmacies, and more.
Kickback Fraud
Another type of fraud is providing referral kickbacks or steering patients toward specific treatments, procedures, tests, or drugs. These kickbacks are illegal payments in exchange for referrals and can be from various sources, such as pharmaceutical companies or physicians. Health 2.0 Conference highlighted that this could also be an example of an improper conflict of interest.
False Claims
Another form of fraud is billing for never rendered services. This could include filing for insurance coverage for patients who never visited the provider, ordering or administering unnecessary tests or procedures, and altering medical records to support higher billings. As discussed at the Health 2.0 Conference, these are particularly hard to detect, but this fraud could lead to insurance companies paying out thousands of dollars in false claims.
Medical Identity Theft
Additionally, medical identity theft is becoming a more significant problem. This occurs when someone steals personal medical information, such as their name, address, Social Security Number, or insurance details, to commit fraud. Health 2.0 Conference alerts that fraudsters may use this stolen information to get medical treatments, drugs, or surgeries and then bill them to the patient’s insurance company. This fraud affects the person whose identity was stolen and can lead to inaccurate medical records for the victim.
As healthcare fraud is a costly issue in the United States and a huge concern for everyone, The Health 2.0 Conference addressed that healthcare providers and insurance companies should also increase their internal fraud prevention programs and have multiple layers of authentication in place.
Fraudulent claims for services not performed or over-billing for services rendered have cost billions of dollars in recent years. The best way to prevent healthcare fraud is to create an adequate system of checks and balances that detects, investigates, and ultimately reduces this fraudulent activity. Here are some effective ways, suggested by Health 2.0 Conference, to reduce healthcare fraud:
Strict Licensure: Require healthcare providers to obtain proper licensure before rendering services to patients. The licensure process ensures that the provider meets educational, work experience, and other criteria, making it more difficult for someone with criminal intent to obtain licensure.
Regular Monitoring: Develop systems that monitor providers’ billing activities and document compliance. Developing effective and comprehensive billing reviews that look at utilization patterns and referrals can be used to flag any suspicious activity or fraud. Health 2.0 Conference advises patients to double-check their billing statements, be wary of anyone offering free tests or treatments that may be unnecessary, and keep their medical information secure. Healthcare providers and insurance companies should also increase their internal fraud prevention programs and have multiple layers of authentication in place.
Comprehensive Data Analytics: Establish effective data analysis techniques that review claims, diagnoses, treatment, payment history, and referral patterns to detect any anomalies. This allows organizations to detect any unusual patterns in data that could indicate potential fraud. Healthcare providers and insurance companies should also increase their internal fraud prevention programs and have multiple layers of authentication in place.
Enhanced Reporting Systems: Set up systems for healthcare providers and consumers to report suspected fraudulent activity or potential abuse. Develop a system where whistleblowers can safely and confidentially report suspected fraud, which is then tracked and investigated.
Compliance Programs: Develop and implement comprehensive compliance programs in organizations to prevent and detect healthcare fraud. The compliance programs should include policies and procedures that address the issue of fraud, detect suspicious activity, investigate potential fraud, and provide disciplinary measures for employees found guilty of fraud.
Health 2.0 Conference shared that the government agencies like the Centers for Medicare and Medicaid Services have created specific programs to combat fraud. This includes additional auditing, penalties for providers caught committing fraud, and incentives for healthcare providers who use technologies to help combat fraud.
Education and Training: Educate providers and other staff on fraud detection, investigation, and reporting processes. Developing awareness training and providing clear guidance on fraud issues will help healthcare organizations reduce and prevent fraudulent activities.
By following these steps, organizations can develop a robust system of checks and balances to lower healthcare fraud in the USA. With an effective compliance program, strict licensure requirements, and vigorous data analysis and reporting, healthcare organizations can make progress in preventing healthcare fraud and reclaiming lost funds. One can attend a healthcare event like Health 2.0 Conference in 2023 in the USA to learn more about healthcare trends and challenges.
