A Way to Fix Healthcare Fraud

A Self-Funded Employer Can Use the Following Approach to Fix Healthcare Fraud on their Employee Healthcare Plan:

1) Obtain a File of Paid Claims with the Provider ID. You Will Likely Not Be Allowed to Have the Allowed Amount. You Will Get Billed Charges Only, But That Is OK.

2) Analyze the High Volume, Low Dollar (Less than $2,000 per claim) Claims

3) Sort Providers by Number of Claims and Look for Little-Known Providers with Large Numbers of Claims.

4) The Possible Fraud: Those Providers May be Waiving the Deductible, Co-Insurance or Copay for the Plan Members.

5) STOP the Fraud: Alert the Insurance Carrier or TPA, Alert the State Department of Insurance.

If the High Volume of Fraudulent Claims Are for Out-of-Network Providers--Change to a POS Plan that Does Not Have Out-of-Network Benefits.

If the High Volume of Fraudulent Claims are for In-Network Providers--Change from a Major Insurance Carrier to a TPA that Can Support a Lower-Dollar Threshold of Auto-Adjudication.

Sources: https://www.ajmc.com/contributor/andr...

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