Beware of Fraud, Waste and Abuse

Fraud, waste and abuse are pervasive in the U.S. health system, estimated conservatively at 1/3 of total costs – that’s more than $1 trillion. What can you do to protect your company from health care fraud?

Fraud, waste and abuse are pervasive in the U.S. health system, estimated conservatively at 1/3 of total costs – that’s more than $1 trillion. What can you do to protect your company from health care fraud?

Health plans, government agencies and law enforcement work aggressively to uncover and eliminate fraud, waste and abuse schemes in health care services throughout the country. In fact, during 2016, the largest apprehension of alleged criminals occurred. Together, they accrued more than $900 million in billed health care charges. These arrests were made possible by sharing of data and methodologies between public and private organizations as part of a unique and innovative initiative called the Healthcare Fraud Prevention Partnership (HFPP). HFPP helps identify the characteristics of outliers in the combined claims information of those participating in Medicare and Medicare, as well as claims from private payers. Each health plan also has its own team of experts reviewing claims to root out fraud, but not every scheme is uncovered by each company. Consequently, this Special Alert highlights key real-time, actionable insights based on information received through Business Group on Health’s participation with HFPP that can help you detect possible fraud, waste and abuse in your health care program.

Categories to Investigate

The following four categories are areas that were investigated successfully.

  1. Genetic testing. According to the HFPP panel, “coding is like the wild, wild west.” Billing is subject to unbundling, interpretation by non-qualified providers (dentists, for example), abnormal referral patterns (suspicious places of service), and excess volume of pharmacogenomic patterns (person with cancer tested for large array of abnormalities).

    Recommended Action: Have your health plan, consultant or health data aggregator review reports on these potential sources of irregularities to identify outliers or other suspicious behavior.
  2. Opioid prescribing.. Fraudulent claims are often associated with the following characteristics:
    • 10 or more opioid prescriptions in a 6-month period;
    • 3 or more prescriptions in 90 days, 3 or more doctor, pharmacy or emergency room visits during this time period; and
    • More than 180 days supply of opioids on hand.

    • Recommended Action: Lock high-risk patients in to a single provider and pharmacy.
  3. Home Health Care Agencies.. Fraudulent claims are often associated with outliers that have at least two of the following characteristics:
    • No recent visit with a supervising physician;
    • No preceding hospital or nursing home stay;
    • Primary diagnosis of diabetes or hypertension;
    • Claims from multiple home health agencies; or
    • Home health readmission shortly after discharge.

    • Recommended Action: Talk to your health plan about available edits or reviews before payments are made in questionable scenarios.
  4. Sober Homes.. These are facilities for people recovering from substance abuse, often serving as an interim environment between rehab and returning to mainstream society. Services provided can include intensive rehab treatment, drug testing and therapeutic meetings. Sober homes are not regulated by the federal government or the states. Many have sprung up, particularly in California and Arizona (Prescott, AZ is estimated to have more than 400). Fraudulent entities are often owned by felons, do not have 24hour supervision and have had cases of abuse and drugs given involuntarily. Many of these fraudulent entities are buying labs and doing testing on-site multiple times per day.

    Recommended Action: Work with your health plan to identify Centers of Excellence or reputable, high quality facilities of this kind. Consider plan design levers, such as excluding out-of-network sober homes subject to appeal, to help direct patients to appropriate facilities. Require urine drug testing to be part of bundled payments rolled into overall cost.
  5. The Business Group on Health has joined HFPP, a public-private collaboration advancing the detection and prevention of healthcare fraud, waste and abuse. As part of this multi-stakeholder group of private payers, anti-fraud associations, state agencies and federal government offices, the Business Group will identify and share actionable insights with member companies based on information received through our participation to help you identify issues impacting the quality and cost of your benefits program.

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