How to maintain the integrity of healthcare programs

The healthcare industry has always been stressful. The COVID-19 Pandemic, and the new wave of infections caused by the Delta variant, have brought the work of healthcare providers, insurers, and government program administrators into the spotlight.

It is more important than ever to prevent and investigate healthcare fraud. The fraudulent claims that plague Medicare and Medicaid, in particular, cost billions each year. This money has been stolen from taxpayers, insurers, healthcare systems, or patients (or a combination of all three). This money could have been used to provide quality healthcare.

Maintaining program integrity is, therefore, essential for the healthcare industry. As a program administrator, insurer, or provider, you know that fighting fraud is a difficult task. How can you quickly detect fraud and conduct investigations before it becomes a multi-million dollar problem?

Fraud in healthcare goes beyond the surface.

Many healthcare providers know how to defraud payers. Some common examples are submitting claims for unutilized services or services not eligible for payment, intentionally overbilling, and falsifying medical records such as dates or frequency. Some healthcare fraud schemes were more complicated and harder to stop.

Henry McInnis was sentenced in February 2021 to 15 years of prison after directing a $150,000,000 Medicare fraud scheme that lasted for nearly a decade. The scheme’s core was telling patients they had less than six months to live to enroll them into his hospice facilities.

Recently, California doctor Lilit Baltaian was arrested for filing over $6 million worth of fraudulent Medicare claims in six years.

These scams are remarkable because they took place over many years and involved numerous people unaware of their involvement. Paper trails, or data trails to be more accurate, can be challenging to trace.

Healthcare programs face unique challenges.

These examples are just a few of the many challenges healthcare providers face in protecting the integrity and effectiveness of their programs. Many other obstacles hinder the fraud investigation, whether it exists or is possible:

They are maintaining fiscal Integrity without Blocking Access to Care. Every healthcare program aims to help people become healthier or at least manage their current health issues. It is essential to pursue anti-fraud and cost-control measures without excluding people who are in need.

They are sorting oceans of data. Identifying fraud, waste, and abuse in programs is difficult and time-consuming. Investigators must figuratively navigate vast seas of data from many different databases. These data sources often need to be linked, making investigations more difficult and time-consuming.

Limited resources. This can include more than the money, time, and people needed to investigate fraud. While some healthcare data systems are improving, many digital investigation platforms must be updated technologically.

Uncertainty surrounding the Affordable Health Care Act has made it difficult to do business. Annually, Medicare and Medicaid regulations change — for example, new deductibles. Changes in policy and other uncertainty can create new opportunities for fraud.

Virtual Investigator

Innumerable providers and transactions totaling thousands of millions of dollars are made daily. It’s easy to understand how criminal or fraudulent activity could go unnoticed with many patients and providers providing treatment and services. To detect fraud, healthcare program integrity specialists must be able to search through large amounts of data quickly.

Thomson Reuters Clear is a platform that unifies data sources to streamline workflows, reveal previously unknown details, and identify fraudulent activities. The platform has a simple, user-friendly interface and allows for quick searches of thousands of data sets.

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