We would like to thank everyone who has visited our blog this month and joined us for our online series about some of the more particular aspects of healthcare reform, particularly our HIPAA 5010 posts. In this blog, we’ll discuss the latest efforts in fraud and abuse prevention.

Fraud and Abuse Prevention Reform

The capital building with the phrase "Healthcare Reform" Fraud and Abuse Prevention Reform Efforts

What are the latest fraud and abuse prevention efforts?

We understand that this topic is extremely expensive, and will come back to visit it again in the future through some of our other posts. Indeed healthcare reform has already began to impact the industry, and will continue to do so in the future. Compliance in healthcare will be impacted, relationships with payers will be affected, and, as we have shown previously,  there will be more of an emphasis on fraud and abuse prevention. September is just around the corner and has been designated by the Centers for Medicare and Medicaid Services(CMS) as Healthcare Fraud Prevention and Awareness Month. We think that this is an excellent time to shift gears and look at the topic of fraud and abuse prevention and awareness.  We hope that you will join us again this week as we continue to explore relevant healthcare topics and engage in conversations with you, our viewers.

In the meantime please feel free to check out this video to become acquainted with the basics of what healthcare fraud is: What is Healthcare Fraud

Examples of Fraud and Abuse In Healthcare

Examples of fraud and abuse in the healthcare system are diverse and undermine the integrity of medical services while contributing to rising costs. Billing fraud is a prevalent issue, with healthcare providers sometimes submitting false claims for services not rendered or inflating the severity of a patient’s condition to receive higher reimbursements. Kickbacks, where healthcare professionals receive improper payments for referrals or services, also plague the system, compromising patient care in favor of financial gain.

Phantom billing is another form of fraud, involving the submission of invoices for fictitious medical procedures or supplies. Additionally, upcoding occurs when providers assign a higher billing code than justified by the actual services provided, leading to overpayment. Unbundling, the separation of services that should be billed together to increase reimbursement, is another deceptive tactic.

Patients can also engage in healthcare fraud by providing false information to obtain services or prescriptions they are not entitled to receive. Prescription drug fraud involves the illegal acquisition or distribution of medications, often for resale on the black market.

These instances of fraud and abuse erode trust in the healthcare system, divert resources from legitimate patient care, and contribute to the escalating costs of medical services. Efforts to combat these issues involve stringent monitoring, auditing, and the implementation of advanced technologies to detect and prevent fraudulent activities in healthcare.

Recent Prevention Efforts

Watch this campaign for fraud and abuse prevention for some interesting statistics on how fraud is impacting healthcare costs:

Until next time!