How to tackle health insurance fraud, waste and abuse: everyone has a role to play
When the medical providers in question were contacted, one confirmed that certain costs had been altered, and the other could find no record of Maia in their system. A review of all claims she had submitted over the past year turned up similar alterations or forgeries as confirmed by multiple providers. Taking a closer look at her five-year claims history, investigators found more than 400 claims – most of which had been altered or fabricated based on a template invoice dating back to 2011.
The end result from this detective work? Maia lost her job and had to repay every bit of the £350,000 she had fraudulently obtained. And an estimated £77,000 in future false claims was saved.
What is considered fraud, waste and abuse?
Maia’s case is just one of many examples of healthcare fraud. When combined with wasteful spending and abuse of the system, the problem collectively called fraud, waste and abuse (FWA) affects every single one of us – from small businesses, corporations and insurers to healthcare providers and individuals. Here is a quick primer on what constitutes FWA:
Fraud – intentional deception or misrepresentation (billing for services not provided; misrepresenting who provided services; altering claim forms or medical documentation; falsifying a patient’s diagnosis to justify tests or surgeries).
Waste – overuse of medical services (medication and prescription refill errors; failure to implement standard industry waste-prevention measures).
Abuse – actions that result in unnecessary costs, improper payments or payments for medically unnecessary services (misusing claim billing codes; performing more tests than care standards call for; billing for services that shouldn’t be covered).
How are we all affected?
The United States’ National Healthcare Anti-Fraud Association (NHCAA) estimates that tens of billions of dollars of healthcare spending is lost to fraud each year. FWA directly affects the financial performance of health insurers as well as the premiums that consumers, private employers and governments must pay. It also results in higher out-of-pocket expenses for individuals and reduced benefits and coverage. And it means that money, care and resources are being diverted away from sustaining and improving global health.
FWA myths
FWA has historically flourished due to several mistaken beliefs. Some people believe fraud is a victimless crime; others feel health services should be provided at all costs, where more care and expensive care are both always better. And still others assume the professional integrity of healthcare providers is sacrosanct. The Fighting Fraud & Corruption in Healthcare in Europe: a work in progress report (2016) outlines many of the issues with FWA.
Taking action
To combat this problem, Aetna’s International Special Investigations Unit works with independent anti-fraud and corruption bodies, such as the European Healthcare Fraud & Corruption Network, to prevent FWA, investigate potential issues, recover funds and report fraud to state and federal agencies.
Individual countries also have their own approaches to reducing FWA. In the US, the NHCAA allows authorised users to effectively share critical information about suspected fraudulent activity through its Special Investigations Resource and Intelligence System. And in the UK, London’s police force maintains an Insurance Fraud Enforcement Department.
Here are some ways you and your employees can protect against healthcare fraud and keep healthcare costs down for everyone.
What employers can do to prevent fraud
- Protect – protect your corporate health insurance policy information. Be careful about disclosing any policy or group scheme information over the internet or telephone.
- Educate – explain to your employees how FWA increases the cost of providing health insurance benefits and puts company and government schemes at risk. Share with them the tips below and other advice to help prevent it.
- Be diligent – select your broker partners and health insurance companies with care. Ask questions about their FWA processes and policies.
- Report – call your insurance company if you suspect your organisation may be the victim of insurance fraud.
What employees can do to prevent fraud
Protect – protect their health insurance ID card just as they would a credit card. Keep their policy number and personal insurance information private and don’t give it out to solicitors by telephone or over the internet.
Report – call their insurance company if they suspect they may be the victim of identity theft or insurance fraud. With medical identity theft on the rise, thieves now use personal health insurance information to steal expensive medical services, equipment and drugs.
Be diligent – keep a close eye on their medical reports, records and invoices. Learn more about medical identity theft and healthcare fraud.
Be informed – read their policy, benefits statements, Explanation of Benefits (EoB) statements and any paperwork they receive from their insurance company carefully. Make sure treatment dates, details, charges and expenses are correct to the best of their knowledge.
Follow the law – be aware that sharing medical coverage with uninsured family members or friends is against the law. This can lead to tainted electronic medical records, incorrect diagnoses for the insured and other negative consequences.
Beware – be wary of offers for ‘free’ healthcare services, tests or treatments. These could be fraudulent schemes designed to bill them and their insurance company illegally for thousands of dollars in services they never received.
This article was provided by Aetna International.
Supplied by REBA Associate Member, Aetna
Aetna is re-shaping and improving health care across the globe by developing solutions.
