Fraud Management
Insurance Institute of India
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Jennifer Nuelle-Dimoulas, COO
February
23, 2012 / Author /
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Table
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Intro to Fraud Management Facts & Figures
Fraud Investigation Findings
Inpatient Benchmarking
Outpatient Benchmarking
Fraud Techniques
Diagrams
Case Studies
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The Importance of Health Insurance
The Institute of Medicine of the National Academies in Washington, DC
reviewed 130 studies published in the past 20 years and found that:
Adults without insurance coverage have worse health outcomes.
Longer-term population-based studies (from 5 to 17 years) find a 25 percent higher
risk of dying for adults who were uninsured at the beginning of the study.
Compared to patients with private insurance coverage
Uninsured patients with breast cancer have 30 to 50% higher mortality rate
Uninsured accident victims have a 37% higher mortality rate.
Uninsured patients with colon cancer have 50 to 60% higher mortality rate
Institute of Medicine of the National Academies - Washington, DC “Care Without Coverage: Too Little, Too Late,” 2002.
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Health insurance coverage matters. Protecting it matters.
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Claims Management
Sophisticated methods
Pre-admission and Outpatient Pre-certification
Pre-surgical Review and Second Surgical Opinion
Concurrent Hospital Treatment Review
Pharmaceutical Review
Length of Stay Determination
Discharge Planning
Case Management
Quality Review Quality Assurance Assessment
Medical Record Abstraction
Surveys and Data Collection
Subrogation - Third Party Liability
Medical Provider Networking
Utilization & Physician Peer Review
Employer / Employee Communication & Education
Services Patient Satisfaction Surveys
Independent Medical Examinations
Appeals Processes
Retrospective Review
Claims Audit
Claims Processing
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•Over the past decade, claims administration has matured dramatically in the
region.
•From the infancy period in the late 80s and early 90s, TPAs and insurers have
achieved a great deal of efficiency in processing claims.
•Governments are facilitating this.
•Data is entered for diagnosis, procedures, surgeries, room & board, etc.
•Data is directly linked to quality as well as fraud control.
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The backbone of all of this is data
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Specifically in the UAE, processing & data collection has been achieved at a tremendous cost.
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Lack of standardized coding and
nomenclature requires individuals to back
map non-coded provider information into
high-tech TPA systems.
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To put it into perspective,
In 2005, 95% of private hospitals document claims to TPAs and
bill insurers with no standards.
100% of private clinics used their own self-made codes or
narrative descriptors.
Private pharmacies billed with narrative names and prices.
Private diagnostic centers send bills with coding, without standards.
Private dental professionals sent narrative bills and charges.
A TPA could potentially see the number of providers in their
network equal number of approaches to send bills and document
claims.
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5 Years Later….
HAAD in 2010 has enforced all private hospitals in Abu Dhabi to
document claims to TPAs and bill insurers with set standards.
Total number = 261
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but….
Observation codes are not mandatory.
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5 Years Later….
Where are the rest?
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A unstructured system is ripe for fraud.
In an independent survey of 700 private healthcare
providers in the UAE found that…
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96% of private providers did not control the Identification of the
Insured Member
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40% of private pharmacies switched medications when asked to.
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35% of private provider did not collect co-participation & deductibles
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30% had untruthful claim forms.
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28% of private providers charged insurance patients more than private pay patients.
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0% of private providers had ethics and compliance programs
0% were aware of UAE Penal Law #390-399 which penalizes fraud
and provides 6 months to 3 years in jail.
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< 2% of group beneficiary guides mentioned anything at all
about the patient’s role in fraud prevention.
Undocumented reports of physicians given base salaries with
commissions on tests, procedures, prescriptions and surgeries.
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What we saw 10 or 15 years ago was fraud with providers in the
periphery of the profession.
Today, it has hit mainstream.
4600 of 5000 hospitals in the USA were billing the government’s
program for elderly (Medicare) twice for the same service.
Major healthcare group and pharmaceutical company convictions
were previously unthinkable.
It is estimated that irregular practices consume from 10 to 30%
of annual healthcare spending
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•Less than 5% of Fraud is Prosecuted
•Contributor to rising health care costs
•Increased premiums
•Decrease access
•Restrictions and limitations on benefits
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Internationally, 25% of patients surveyed think its acceptable to
recover a deductible by raising a claim amount.
Nearly 1/3 of patients surveyed in worker’s compensation claims believe
it is acceptable to stay home and receive compensation because they
feel pain even though their doctors could certify they were able to go
back to work.
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A Hard Fact.
Healthcare fraud is most common in countries where healthcare providers or
hospitals bill health insurance companies for services or supplies rendered.
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Another Hard Fact.
Among hundreds of thousands of claims filed each year, finding the irregular ones
is no easy task.
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Generally they are not obvious and are difficult to detect and include:
Receiving payment of kickbacks or bribes in exchange for referral
Balance billing patients for PPO discounts
Providers billing for services not provided
Providers administering more tests and treatment or providing equipment that are
not medically necessary
Providers administrating more expensive tests and equipment Multiple-billing for
services rendered
Unbundling or billing separately for tests performed together to receive higher
payment
Providers charging more than peers for the same services
Policyholders letting others use their healthcare cards.
Altering the quantity or number of refills on a prescription
Falsifying claims
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Ideally, it is best to audit all claims carefully.
Not feasible with the growth of the insurance industry and cost of
doing business.
Under pressure from providers, groups and insurers, many times an
organization is faced with making an unacceptable trade-off between
higher processing efficiency and losses due to irregularities.
Most of us know the reality.
If the data was submitted standardized, efficiencies would be
improved monumentally.
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The UAE is on its way from
this….
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HCPCS or Tailor made
options for consumables &
DME
Uniform
Claim Form
To this.
Other Standards for Dental
Behavioral health, Coding
of Drugs, Procedures
ICD9CM / ICD10
for diagnosis
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Government Authorities have published and mandated
minimum data sets to monitor and report on activity and quality.
2010 was the beginning. Data is being collected from all entities providing
healthcare and health insurance within the health sector.
PBM, e-authorization, e-prescription and DRGs April 1, 2012.
As well as sophisticated solutions for edits, electronic fraud detection
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Private payers, TPAs and Providers have initiated partnership and taken first steps
in making recommendations to expand uniform standards to submit claims data
and report.
Taken in partnership with government authorities to build on what the
government has achieved.
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Creates a shared language for healthcare organizations,
increasing consistency and transparency, facilitating
discussion and enabling for efficient electronic communications
between healthcare organizations.
Data will become a byproduct of the routine operations of
providers and insurers, rather than creating an additional or
separate burden of information collection.
Improvement of monitoring and patient care
with continued dialogue as we move collectively
forward.
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And along the way to more robust standards,
we will also continue our parallel efforts.
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Analysis of Provider Behavior & Billing
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Inpatient Benchmarking
Component
Surgery, Anesthesia, OT, Surgeon’s Fees
Medications
Room & Board
Lab
Consumables (varies)
Radiology
Doctor’s Rounding
Consumables
Special Equipment
Inpatient
35-40%
25-30%
5-10%
5-10%
12-15%
6-8%
3%-5%
10-15%
5% (variable)
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Outpatient Benchmarking
Component
Outpatient
Consultation
20%
Procedures
20%
Laboratory & Radiology
20-30%
Medications
30%
Miscellaneous
5%
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Multiple Levels of
Claims Scrutiny
1. Pre-certification
2. Concurrent Review
3. Retrospective Review
4. CMUR
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Member & Provider
Education & Awareness
1. Case of Provider Rehabilitation
2. Seminars to HRs, Groups
3. Inclusion in Beneficiary Users
Guides
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Formalized Fraud Unit
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Investment in Formalized Fraud Department
Development of Vision, Mission, Performance Objectives
Formal structure and reporting lines to COO and CEO
Process flow / documented procedures/ guidelines
Close Collaboration with Legal Department
Formalized Internal and External Reporting
Whistle blowing procedure, confidential 800-hotline, anti-fraud publications
Zero tolerance to fraud reflected in network contract wording, insurance policy
wording, beneficiary users guides
Case management: threshold investigations
Regular exploration and mystery shopping
Response and misconduct management
Training and awareness-raising
High risk Assessment of providers and patients
Exposure, action and prosecution
Cooperation with Government and other stakeholders
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Contact
Jennifer Nuelle-Dimoulas
Chief Operations Officer
NEXtCARE UAE AGHS LLC
Business Avenue Building
10th Floor
Sheikh Rashid Road, Deira
P.O. Box 80864
Dubai, UAE
Phone +971 4209 5200
Fax +971 4209 5302
Jennifer.nuelle-dimoulas@nextcare.ae
www.nextcarehealth.com
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