Health Care Fraud – The Costly Deception?

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For years significant resources have reportedly been directed towards combating  health  care fraud by insurers, regulators, law enforcers and legislators. Yet, despite these reported efforts, it would appear, based on the annual estimates, the problem continues to grow and flourish.

Could this indicate that  health  care fraud is at epidemic proportions and can’t be stopped as our  health  care system is infested with  health  care providers who will stop at nothing to make a buck? I think not.

My experience, over two decades of working with insurers, law enforcers, regulators and  health  care providers, suggests that most  health  care providers are honest, ethical and strive to do the right thing!

Additionally, my experience has provided me with the opportunity to see the fraud problem from both sides, that of enforcement and the provider. When viewed from both perspectives, it is readily apparent that our  health  care fraud problem is caused by a number of factors, including:

1. Inadequate education for  health  care providers relative to coding and payer standards.

2. Deviant providers.

3. Inadequate training for claims handlers and claims investigators on coding and provider standards.

4. Inept claims handling and claims investigations by insurers prior to paying claims.

5. Lack of communication from insurer to provider on what is required.

6. Paucity of reliable training for law enforcers regarding the investigation of  health  care fraud – from identification to prosecution.

7. Tag-a-long investigators looking for organizational stats resulting in the inefficient use of law enforcement resources.

8. Lack of interest or commitment by prosecutors – big cases big problems, little cases little problems.

9. Lack of accountability for all segments of the  health  care delivery system – provider, payer, regulator and enforcer.

Insurers, the main reporter and victim of the fraud, indicate that all policyholders pay for the fraud in the form of higher premiums. According to the National Insurance Crime Bureau, the average American household will pay $200 more every year in premiums to pay for the fraud.

Insurers are very aggressive in reporting how costly the problem is, revealing estimates of double-digit percentages of claims submitted that are fraudulent, and billions of dollars lost each year due to fraud. These reports and estimates weigh heavily in the minds of state insurance regulators when they allow insurers to raise premiums.

Basically, what insurers and others refer to when they reveal their estimates on the frequency and costs of  health  care provider fraud is the billing for services not rendered, billing for services that are substandard and/or unnecessary, billing for services that misrepresent the nature of the service provided, billing for services that misrepresent the actual service provider…

The sweeping nature of the attention  health  care providers are getting, even those not engaged in fraudulent activity, by insurers in post-payment audits is unprecedented, and may take away from the ability of our  health  care providers to do what they do best – make people better! It is unfortunate that today,  health  care providers may spend more time documenting and defending their services to a multitude of sources, to include insurers, regulators and law enforcers, then they do providing  health  care services to patients.

 Health  care fraud is a crime that should be dealt with swiftly, responsibly and severely! But,  health  care fraud should not be used as a vehicle for one to prosper at another’s expense. Insurers are in the business of making money, and they are doing just that, making money – making a lot of money! This money comes from premiums collected on the sale of policies to consumers seeking protection from future (unknown) losses.

Many insurers are in a position to limit their potential  health  care claims exposure as they possess the ability to tell insureds’ what doctor they can see, what treatment services they can get, and how much will be paid for the services.

Further, insurers may capriciously limit payment on  health  care claims denying  health  care services reported by  health  care providers, asserting the services were illegitimate, claiming the services were fraudulent. Many insurers conduct claims-evaluations, reportedly for the purpose of determining if the  health  care services rendered by the provider were usual, customary and/or reasonable (UCR). Consider that by definition, “fraud is the knowing and willful deception or misrepresentation of the facts with intent to receive an unauthorized payment.”

Wouldn’t such an evaluation be considered a fraud evaluation? It is purportedly done for the purpose of determining if the  health  care provider misrepresented the nature of the services provided and reported, i.e. fraud.

Unfortunately, the UCR evaluation seems to have little to do with actual fraud fighting, but everything to do with cost containment and the bottom line for insurers. These evaluations typically do not identify that the  health  care provider did not provide the reported services, but instead report subjective opinions of consultant providers who usually do not even see the patient. In many cases, insurers may successfully reduce the  health  care provider’s billings using UCR evaluations – not because the evaluations were accurate, but because the  health  care provider did not have the knowledge or necessary resources to fight back.

The effectiveness of these evaluations as a means to combat fraud is questionable, and may be non-existent.

Check with your state insurance regulators and  health  care boards to determine if insurers refer their UCR evaluations to them for fraud investigations, and, if so, ask them how many. Ask your local law enforcers how many cases they investigate or prosecute that were based on UCR evaluations.

Further, ask your insurer what percentages of their estimated losses due to  health  care fraud include UCR evaluations. And, ask your insurer why, with their duty and ability to examine all claims, are they unable to do a better job in not paying fraudulent claims.

Interestingly, since the late 1980’s,  health  care providers have had a standard coding system. This system, known as Current Procedural Terminology (CPT), is used by providers to report and bill for  health  care services rendered to patients.

CPT was promulgated by the American Medical Association (AMA) so that all  health  care providers, regardless of discipline, could accurately report their services and be compensated for services rendered.

Although CPT has been around for decades, there are no standards of education and training required of  health  care providers for the proper use of the codes, or insurers for what the codes mean. This may lead to a systematic problem in our  health  care system, as an unnecessary adversarial system is created between our  health  care providers and  health  care payers based on an ‘attack and defense’ of billing codes and treatment records.

Both are looking at the codes, viz., one for the purpose of reporting services to seek compensation, and the other for determining what they will pay.

It should be evident, from the annual reports, if they are accurate, that our  health  care fraud problem will not be solved solely by amassing a large amount of resources to attack the problem, creating consortiums to share information and research the problem, or with the introduction of additional laws or regulations from politicians stumping for re-election. The investigation of  health  care fraud for the purpose of prosecuting the offenders is needed. But, also needed is a mandatory educational process for our providers, insurers and investigators on combating  health  care fraud.

The  health  care fraud problem is too complex to be battled by the few.  Health  care fraud is a problem that demands a greater participation by the principals of our  health  care system, so as to increase the likelihood that our successes in combating this costly problem will be enhanced, identifiable and verifiable.

 Health  care fraud is a problem – just read the news, but it is a problem that can and must be successfully addressed. This will only happen once our fraud-fighting team is completely accountable and includes the active participation of  health  care providers.

There is no stronger voice against  health  care fraud then that of honest and ethical  health  care providers – who, by the way are also insurance and  health  care consumers and part of the premium paying public. Most  health  care providers do not engage in fraud and would like to see those who do be stopped and put out of business. However, the current fraud fighting arena has  health  care providers – even the honest and law-abiding ones, pitted against insurers and others.

 Health  care providers who are not engaged in fraudulent activity must endure aggressive and invasive encounters with insurers to get paid for legitimate services provided. This process has a counterproductive effect on our overall success in combating  health  care fraud.

 Health  care providers who are not engaged in fraudulent activity may possess information and knowledge that would be useful in assisting  health  care fraud fighters. These providers could potentially assist at the street-level on the identification of  health  care providers engaged in fraud.

Furthermore,  health  care providers who are not engaged in fraudulent activity may assist fraud fighters with establishing the evidence to support prosecutions of the fraud. However, with the current adversarial system,  health  care providers who are not engaged in fraudulent activity may have neither the opportunity nor desire to assist fraud fighters as they are fighting payers for their mere financial existence.

Maybe it is time the various  health  care disciplines and  health  care provider associations formed an alliance to be the provider’s action arm to work closely with law enforcers in attacking insurance and  health  care fraud, just as the insurance industry purports to do. And, just maybe, with such an alliance, we would actually see a drop in the annual estimates of the costs attributed to  health  care fraud – currently they range, depending on the source, from $20 to $160 Billion.


Source by Daniel J Osborne



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