Fraud in the Healthcare System

Posted by on Feb 23, 2014 in Best Practices, Blog, Health Care, Legal Nurse Consultant, Legal Nurse Consulting, Litigation Tools

Better Education and Technical Know-how Can Combat the High Cost of Fraud The FBI estimates that healthcare fraud costs the country an estimated $80 billion a year!  It’s the Number One factor responsible for the country’s astronomical increases in healthcare costs. Fraud defined The National Health Care Anti-Fraud Association says that healthcare fraud is “an intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual or the entity or to some other party.” Fraud and abuse can come in many forms.  It can include acts (and inaction) committed by providers as well as patients.  Providers may, for example… Bill for services not provided Duplicate submission of claim for same service, Misrepresent the service provided, and Bill for a covered service when the service provided was actually not covered Plan Members may abuse the system by… Doctor shopping Filing for reimbursement on services or medications not received or performed Falsification of information or injury Forging or selling prescription drugs, and Using transportation benefit for non-medical related business Why is healthcare today so vulnerable to fraud?  One reason is that medicine has become much more complex, and the doctor-patient relationship has changed.  For instance, a patient nowadays might be under the care of multiple providers, and each provider might not have a clear picture of the patient’s plan of care. Another reason the system is vulnerable to fraud relates to constant changes in billing and coverage.  Terms and conditions of reimbursement often change, too, and they’re highly technical and arcane.  Moreover, the urge – whether cultural or economic – for quick fixes creates opportunities for fraud. What’s being done about it? Various public and private-sector anti-fraud organizations have formed.  Through education and working with lawmakers and regulators, they’ve made progress preventing fraud and reducing its cost to the system.  The legal nurse consultant is another resource to which many fraud investigators have turned for the technical knowledge and experience it often takes to spot a fraudulent medical claim. Jordan Ilderton, RN, BSN is a Legal Nurse Consultant with MKC Medical Management.  Contact Jordan at...

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Need to really understand a claim?

Posted by on Feb 5, 2014 in Best Practices, Blog, Case Management, Claims Tools, Legal Nurse Consultant, Legal Nurse Consulting

Need to really understand a claim? Then understand the Mechanism of Injury Understanding and accurately interpreting the Mechanism of Injury are essential to determining if an injury is directly related to an event or accident. Making sense of the facts Insurance claims typically assert that someone with an injury fell in a certain direction and extended their arms to break the fall. In the case of motor vehicle accidents, claims usually detail the placement of an individual in the vehicle, whether they were restrained, the point of impact, speed, and so on. An individual in a car with a rear-end collision, for example, will potentially have much different injuries than someone who is hit from the side at a high rate of speed. These pieces of factual context are used to understand injuries and the legitimate basis for claims. Related or unrelated? Claims often include treatment for injuries related to an accident which are entwined with non-injury diseases or conditions. In addition, medical providers often identify and treat solely on the injury description provided by the patient – whether related to an injury or not. In order to untangle what is not directly related to the injury, there has to be a clear understanding of the injury details and Mechanism of Injury. Appropriately trained and experienced medical providers can separate related and unrelated parts of a claim and reduce the overall claim exposure. That’s because they understand Mechanism of Injury and its physical effects. The bottom line Injuries can be caused by a single event or can have multiple factors, and the presence of risk factors can make the individual more prone to injury. Once the Mechanism of Injury has been clearly identified, attention should focus on potential causes (e.g., internal/external risk factors, pre-existing conditions). The ultimate goal is to ensure appropriate treatment only for injuries directly related to an event. This can help produce cost savings and reduce claims exposure. Debra West is a Registered Nurse and Legal Nurse Consultant with MKC Medical Management, Inc. Contact Debra at or at...

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