FRAUD & ABUSE
PROVIDERS PERSPECTIVE

PROVIDERS PERSPECTIVE
Examples of Fraud by Providers
• Billing for services that were not provided
• Performing medically unnecessary services
• Altering claim forms, medical documentation , etc.
• Duplicate billing (deliberate)
• Exorbitant or “ exploding” charges
• Billing for a service that costs more.
• Offering, or receiving a kickback for referral of patients in exchange for other services.

PROVIDERS PERSPECTIVE
( Contd)
• Misrepresenting non-covered services as medically necessary, e.g., billing “nose jobs” as deviatedseptum repairs, routine foot care as diabetic foot care
• Using another person’s ID card to obtain care services

PROVIDERS PERSPECTIVE
Prescription / Drug Fraud
• Pharmacy dispensing a generic but billing for a brand
• Patient selling drugs back to the pharmacy for pharmacy to re-sell
• Prescription forging/altering.

PROVIDERS PERSPECTIVE
Prescription / Drug Fraud (contd)
• Incentives to physicians to prescribe medically unnecessary drugs/brand names (manufacturer)
• Counterfeit drugs through black/grey market
(wholesaler)

Examples of Abuse
• Charging in excess for services/supplies beyond tariff.
• Providing medically unnecessary services
• Providing services that do not meet professionally recognized standards

Difference between Fraud & Abuse
• Fraud requires evidence of intent to defraud, i.e., acts were committed knowingly, willfully and intentionally.
• Abusive billing practices may not result from “intent” or it may be impossible to prove that the intent to defraud existed; however under certain circumstances, these types of practices may develop into fraud

What Insurance Cos expect from Providers
• Providers should
– Not charges more than tariff.
– Maintain proper records of patients for future reference.
– Not advice unnecessary test or un-indicated tests.
– Do not issue wrong medical history or modify history after the claim.
– Cooperate with Ins Cos/ TPA to give details of any patients in case of deficiencies.
– Not exploit patients
– Not sell Medicines/ Implant/ materials without supporting invoices.

What Provider Expects from Ins. Cos/ TPA
• Inform patients(proposers) about
– diseases covered & excluded before policy is issued.
– maximum amount payable for a particular disease.
– Co-payment if any payable.
• Don'ts
– demand unnecessary papers from hospital not related to disease

What Hospital Expects from Ins. Cos/ TPA
• Don'ts(contd)
– Harass doctors during busy schedule
• DO’s
– Quick response in case of cashless admission
– Releasing promised amount within 15-30 days
– Separate grievance cell
– Skilled & qualified processing team
– Update about any change in policy conditions to the hospitals.

What Hospital Can Do to avoid Frauds/ Abuses
• Corporate hospitals can keep check on individual doctors involved in fraudulent practice.
• Small nursing homes/ Hospitals- difficult but, if anyone notices should be reported to local association.

What Ins. Co/ TPA Can Do to avoid Frauds/ Abuses
• Collect Data of doctor/ hospital involved in such practice and share.
• Appoint spot investigators for suspicious areas/ hospital/ doctors(during admission).
• Investigation in Reimbursement claims
• Decide tariff of various ailments with related complications considering
– location of hospital
– Status of doctor
– No of beds & facilities(Single or Multi Specialty)
– Data from various hospitals

What Ins. Co/ TPA Can Do to avoid Frauds/ Abuses
• Why Preferred Provider Network(PPN) did not work
– Non appealing
– Advantage for small town & peripheral hospitals
– No proper communication to patients
– Conditions

What Ins. Co/ TPA & Providers can do to avoid
Frauds/ Abuses
• Involve local association to decide tariff for various ailments .
• Printing of Charges(in the policy) of common ailments & its limits in various hospital( A, B, C D category).
• Punitive measures against those hospitals & doctors involved in fraud & abuse.( Should be printed in policy).
• Blacklist hospital/doctors & Insurance agents involved
• Common policy conditions & claim forms.