Why the integrity of health care programs is important

Health has always been a stressful activity. The COVID-19 pandemic and now the latest wave of infections caused by the Delta variant have put the work of providers, insurers and administrators of government health programs in the spotlight.

This makes the prevention and investigation of healthcare fraud more difficult and important than ever. Fraudulent claims, which plague Medicare and Medicaid in particular, cost tens of billions of dollars a year. It is money stolen from patients, insurers, health systems or taxpayers (or any combination of these). And that is money that could be used to provide quality care.

This is why maintaining the integrity of the program is so essential for the healthcare market. Whether you are a supplier, an insurer, or a program administrator, you know that your efforts to fight fraud face many challenges. How can you investigate and quickly uncover fraud cases before they turn into multi-million dollar issues?

Healthcare fraud schemes aren’t just superficial

Many providers know how healthcare payers can be defrauded. Some of the more common examples include submitting complaints for services that were not used or were not eligible for payment, intentionally overcharging, and falsifying medical record information such as dates or frequency of claims. services provided. But there have been healthcare fraud schemes that were much more complex and difficult to stop.

In February 2021, Henry McInnis, CEO of a Texas-based group of hospice and home care providers, was sentenced to 15 years in prison for running a $ 150 million Medicare fraud program that lasted almost a decade. The heart of the program was falsely telling patients that they had less than six months to live in order to enroll them in his company’s hospice facilities.

More recently, California doctor Lilit Baltaian was arrested and charged with submitting more than $ 6 million in fraudulent health insurance claims over a six-year period.

What is remarkable about these scams is that they have occurred over a period of several years, involving many people unaware of their participation. Paper traces – or more precisely, data traces – can be extremely difficult to trace.

Health programs face unique challenges

The above examples highlight just a few of the challenges healthcare providers face when it comes to protecting the integrity of their programs. There are many other obstacles that hinder the investigation of an existing or potential fraud:

  • Maintain fiscal integrity without blocking access to healthcare. The ultimate goal of any health care program is to help people recover, or at least manage their health problems better. It is therefore essential to vigorously pursue cost control and fraud control measures, without inadvertently interrupting those who really need them.
  • Sorting the oceans of data. Identifying program fraud, waste and abuse is time consuming and complicated. This forces investigators to swim figuratively through vast seas of data, often from multiple databases. In addition, these data sources are usually not connected to each other, making surveys even more cumbersome and time-consuming.
  • Limited resources. It can refer to more than the time, people and money required to prosecute fraud cases. While some health data systems improve, many digital forensic platforms are technologically obsolete.
  • Changing regulatory and policy requirements. The uncertainties surrounding the Affordable Care Act over the past few years have made things difficult. Changes in Medicare and Medicaid rules – new deductible levels, for example – are annual events. Policy changes and other uncertainties can open up new opportunities for fraudulent claims.

A virtual investigator

There are countless suppliers and countless transactions involving thousands and millions of dollars. With so many patients and so many providers offering treatment and services, it is easy to see how criminal and fraudulent activity can go unnoticed. Health care program integrity specialists need a way to quickly search massive amounts of data in order to reveal potential fraud.

Thomson Reuters CLEAR is a digital platform that unifies multiple data sources to streamline your workflow, uncover potentially unknown details, and help you identify fraudulent activity. It features user-friendly navigation and easy-to-use filtering that lets you quickly search for thousands of datasets and spot red flags of fraud.

Thomson Reuters is not a consumer information agency and none of its services or the data it contains constitutes a “consumer report” as that term is defined in the Federal Fair Credit Reporting Act (FCRA ), 15 USC sec. 1681 and following. The data provided to you cannot be used as a factor in the decision of consumer debt collection, establishing a consumer’s eligibility for credit, insurance, employment, government benefits or housing. , or for any other purpose authorized under the FCRA. By accessing any of our services, you agree not to use the service or data for any purposes permitted under the FCRA or in connection with taking adverse action relating to a consumer claim.

About Mike Stevenson

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