What Your Healthcare Company Can Do About Fraud
Healthcare insurance fraud is big problem. It is a crime. It can also involve vast sums of money. Let’s be clear; simply stated, healthcare fraud occurs when a dishonest medical provider or a consumer intentionally submits, or causes someone else to submit, false or misleading information to make a claim for reimbursement.
Healthcare Fraud has been widespread for years and has increased this past year due to the COVID-19 Pandemic.
Insurance companies are always working to monitor and prevent healthcare fraud, especially because it can take so many different forms. They have fraud departments to track and dispute claims and will call the authorities if they suspect a crime has occurred. Here are some examples of the most common frauds:
- Billing for services that were not actually performed. This is also called “Phantom Billing” and is often associated with Medicare fraud.
- Billing a higher price for one or more drugs than the actual price for the drugs)that were administered.
- Falsification of a patient’s diagnosis to justify tests, surgeries or other medical procedures that are unnecessary
- Misrepresentation of procedures performed to obtain payment for non-covered services, such as cosmetic surgery
- Provider overbilling or “upcoding fraud” which is billing for a more costly service than the one actually performed by the provider.
- Unbundling – billing each stage of a procedure as if it were a separate procedure
- Accepting kickbacks for patient referrals
- Waiving patient co-pays or deductibles and over-billing the patient’s insurance company or benefit plan the difference
- Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract
In many instances, fraudulent claims occur because of the speed of transactions between banks or credit card companies which post charges in one day.
In large scale enterprises and insurance companies it is difficult for accounting departments to readily recognize healthcare fraud. There generally has to be an obvious pretext for the insurance company to monitor a provider or individual case.
It’s understandable that fraud detection and protection is difficult given the scale of medical insurance fraud.
$3.6 trillion was spent in 2018 on health care in the United States, according to The National Heath Care Anti-Fraud Association, (NHCAA). The NHCAA also reports that approximately $300 billion or nearly 10% of all healthcare spending were fraudulent claims.
AI Can Protect Your Company from Healthcare Fraud
Taking proactive steps to prevent fraud and is crucial with the financial stakes involved. Healthcare and insurance frauds raise the cost of healthcare and medicine for everyone.
The advent of Artificial Intelligence now makes real time monitoring and predictive analysis of fraud possible. The leader in providing healthcare and medical fraud protection is ToolCASE and its proprietary software, RembrandtAI.
Your fraud or accounting department can use the RembrandtAI suite of software to potentially save you millions of dollars based on the size of your business and work force. Besides detecting and protecting your company against fraud, it can resolve customer inquiries, process authorized expenses, and assures regulatory compliance.
Installation can be done in a matter of days or weeks, not months. Informant, one of the key products provided by ToolCASE, is a full risk management solution that monitors all transactions across all types and channels of transaction in real-time.
And it does so with interactive capability. Monitoring takes place on a dashboard that provides you alerts and visualization of transactions.
The ToolCASE RembrandtAI suite of software detects and protects your organization against healthcare fraud, and so much more.