Fraud Detection And Prevention In Healthcare

Each year, healthcare fraud and abuse cases cost the industry billions of dollars. If the fraud detection and prevention activities fail to exist, the revenue and reputation of the health providers could be put at stake.

Multiple abuse laws and healthcare frauds at local and state levels are faced by the providers. In order to resolve this exponentially increasing market issue there is a need to combine healthcare technology and information systems.

Organizations like digital harbor use these technologies which are absolutely necessary for improving healthcare information technology.The dharbor specially help in preventing wrong information capture, payment of unauthorized benefits and intentional misinterpretation. A complete healthcare fraud prevention involves all administrative, legal and technical aspects for running a healthcare organization.

The most common types of healthcare frauds include:

  • Ineligibility for the policy but the constant use of it
  • Paying visit to multiple doctors for collection of multiple prescriptions
  • Claiming injury of a fake accident for receiving medication, care and reimbursement
  • Claim exaggeration
  • Addition of an ineligible person to an insurance policy with incorrect information
  • Using healthcare benefits in order to pay for prescriptions not provided by the doctor
  • Giving your insurance card and allow them to use your identity in order to receive healthcare services
  • Giving away forbidden referrals for certain health services

Development of a strong compliance programs is important for preventing healthcare frauds. Some of the unavoidable practices of fraud prevention include:

  • Creating and distributing a conduct of standards and policies that promote the compliance of commitment of the hospital and the claim management and finance relationships of with other providers
  • Provision of training of the staff and proper education regarding the frauds
  • Chief compliance officer and other staff should be appointed with the monitoring the compliance program sending reports to the governing body
  • Conduction of audits in order to track adherence and help reduce issues
  • In order to respond to healthcare frauds and abuse, new system should be established
  • Undertake correct disciplinary actions against the people who break the laws and policies
  • Maintaining a process for receiving complaints and healthcare fraud reports and creations of procedures for protection against anonymity from retaliation.
  • In order to reduce fraud health insurance companies and the government organizations should establish relations with global technology partners which can help them capitalize on the power of information technology, especially smart card technology. It becomes necessary the partners and vendors are engaged in long lasting experiences, authentication and strong identification.

Documents, coding and billing process addressing in order to avoid fraud attempts

Clinical documents are based upon where the reimbursement of the providers is occurring at the hands of the payers.  Incorrect and inappropriate coding can lead to healthcare fraud and abuse.

Common coding issues and clinical documentations include billing for the following:

  • Medical procedures that are unnecessary
  • Tests or processes of such low quality that they are considered worthless
  • When an unqualified or improperly supervised employee performs the services
  • The services that remain un-rendered
  • The global fee already includes separate services

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