Medical Billing Fraud and Abuse... How to Stop It.

Medical Billing Fraud and Abuse... How to Stop It.  Hospital and Doctor fraud and abuse accounts for 3-10% of all healthcare spending.

This means, a company with 1,000 employees is spending $300K- $1M per year as a result of fraud and abusive billing practices.

Doctor and Hospital may engage in 'Upcoding' to maximize reimbursement.  They do not view changing codes to maximize reimbursement as 'Upcoding,' but there is a fine line between correctly coding and 'Upcoding.'

Insurance companies often deny claims and require prior authorization.  However, these practices do not stop fraud and abuse.  Often the denials and prior authorizations miss the fraudulent claims and abusive billing practices.

Solutions include: 1) Become Self-Funded and review your own claims, 2) Move away from Fee-for-Service to non-claims-based healthcare services such as an on-site or near-site clinic or direct contracting.

Sources:
https://journalofethics.ama-assn.org/...

https://www.ncbi.nlm.nih.gov/pmc/arti...

https://academic.oup.com/cid/article/...

https://www.commonwealthfund.org/publ...

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