Friday, February 1, 2008

Once again, open door to FRAUD, compliments of our government

MDs May be Slow HIT Adopters - CMS and Insurers are Not!

Staff Writers

Did you know that Medicare and private health plans increasingly have been “mining” medical claims data for potential fraud – for some time now – and with the help of sophisticated computer technology?

Yes, it seems true – and such IT may be needed more than ever in 2008!

How Much Fraud?

Fraud accounts for an estimated 3% to 10% of the $2 trillion spent annually on healthcare in the U.S. Within the past few years, companies including Fair Isaac, IBM, ViPS and Ingenix, a subsidiary of UnitedHealth Group, have developed software that detects suspicious patterns in claims data.

“Spider-Web” Technology

According to the CMS, their technique is called “spider-webbing.

IOW: Find one common denominator and follow the thread.

“Red flags” indicating possible fraud include medical providers charging more than peers; providers who administer more tests or procedures per patient than peers; providers who conduct medically “unlikely” procedures; providers who bill for more expensive procedures and equipment when there are cheaper options; and patients who travel long distances for treatment.

Private Insurers to Follow CMS

For example, Aetna reported its fraud-detection software helped the insurer prevent more than $89 million in fraudulent reimbursements from being paid last year, compared with $15 million it was able to recover after fraudulent payments were already made.

Companies are able to save far more money by detecting fraud before claims are paid than recovering the money after the fact.


And so, what are your thoughts on this HIT initiative? Are the private insurance companies and CMS taking advantage of the slow HIT adoption of medical providers? Who is to blame, if anyone?

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Original source: USA Today 11/07/06

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