What Should Health Care Organizations Do to Reduce Billing Fraud and Abuse?

Abstract

Whether physicians are being trained or encouraged to commit fraud within corporatized organizational cultures through contractual incentives (or mandates) to optimize billing and process more patients is unknown. What is known is that upcoding and misrepresentation of clinical information (fraud) costs more than $100 billion annually and can result in unnecessary procedures and prescriptions. This article proposes fraud mitigation strategies that combine organizational cultural enhancements and deployment of transparent compliance and risk management systems that rely on front-end data analytics. Fraud in Health Care Growth in corporatization and profitization in medicine, 1 insurance company payment rules, and government regulation have fed natural proclivities, even among physicians, to optimize profits and reimbursements (Florida Department of Health, oral communication, September 2019). 2 According to the most recent Health Care Fraud and Abuse Control Program Annual Report, in one case a management company "pressured and incentivized" dentists to meet specific production goals through a system that disciplined "unproductive" dentists and awarded cash bonuses tied to the revenue from procedures-including many allegedly medically unnecessary services-they performed. 3 This has come at a price: escalating costs, fraud and abuse, medically unnecessary services, adverse effects on patient safety, 4 and physician burnout. 5 Breaking the cycle of bad behaviors that are induced in part by financial incentives speaks to core ethical issues in the practice of medicine that can be addressed through a combination of organizational and cultural enhancements and more transparent practice-based compliance and risk

Are health care scams infectious? Empirical evidence on contagion in health care fraud

“…Accordingly, researchers have started devoting attention to the drivers of health fraud, and governments have begun focusing on greater accountability and monitoring of the health sector (see Drabiak & Wolfson, 2020;Kang, Hong, Lee, & Kim, 2010;Krause, 2004;Rashidian, Joudaki, & Vian, 2012). (https://oig.hhs.gov/reports-and-publications/hcfac/index.asp).…”

“…Second, the health economics literature has been concerned with analyzing the benefits and funding of health services, with an increasing focus on cost-containment over time (Berwick & Hackbarth, 2012;Morris, 2009;Rai, 2001). Within the cost containment focus has been the attention on limiting or eliminating health care fraud (see Drabiak & Wolfson, 2020;Fan, Zhang, & Fan, 2019;Savino & Turvey, 2018). In this overall spectrum of scholarship, there has been limited or no formal attention to spatial spillovers of health care fraud and the present work attempts to make a contribution.…”

Leveraging law and ethics to promote safe and reliable AI/ML in healthcare

“…NLP can also serve as scribe to take notes, using AI/ML as a filter to record only the most important points and directly input them into the clinical record. Finally, following the patient visit, AI/ML can assist with coding, billing, and internal automated fraud or abuse detection (2,8,9). could oversee feeding this data into the CDS, which would compare this information along with guidelines against an intervention threshold to provide a recommendation (4).…”

Fraud Claims Filed Involving Practicing Ophthalmologists from 1985 Through 2020

“…Fraud, the practice of making a false or misrepresented claim, is an issue contributing to inefficiencies, high healthcare costs, and waste in the practice of medicine. 1 , 2 Fraudulent activity contributes to 3–10% of total health spending and more than $100 billion annually. 2 The fight against fraud is costly as well — from 2011 to 2020, the federal government allotted $350 million to fighting Medicare fraud.…”

“… 1 , 2 Fraudulent activity contributes to 3–10% of total health spending and more than $100 billion annually. 2 The fight against fraud is costly as well — from 2011 to 2020, the federal government allotted $350 million to fighting Medicare fraud. 3 While physicians may not intentionally commit fraud, studies show nearly all physicians will contribute to improper payments at some point in their careers.…”