B4 Reducing Fraud & Abuse in Health Insurance
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Transcript B4 Reducing Fraud & Abuse in Health Insurance
HEALTH INSURANCE FRAUD
GHANA’S PERSPECTIVE
NHIS@10 Conference
Dr. Lydia Dsane-Selby
Director, Claims
5th November 2013
Outline
Definition
Motivators
Types of Fraud & Abuse
Prevention/Mitigation
Pre-payment methods
Post –payment methods
The Way Forward
Definition
FRAUD:
• The crime of deceiving somebody in order
to get money or goods illegally.
• Intentional deception perpetrated for
profit or to gain some unfair or dishonest
advantage
Health Insurance Fraud
Health insurance fraud is an intentional act of
deceiving, concealing, or misrepresenting
information that results in health care benefits
being paid to an individual or group.
Fraud can be committed by both a member and
a provider.
Motivators - Providers
Wide range of potential medical conditions and
treatments to choose from
Fidelity to patients
Exploitation of loopholes in the provider payment
system
Inadequate fraud prevention and detection amongst
insurers
Often seen as a “victimless” crime
Limited sanctions and legal deterrents against public
sector facilities
Motivators - Members
Misconceptions about insurance – victimless crime,
insurers have lots of money
Mutually beneficial to parties involved
Exploitation of loopholes
Financial gain
Limited legal deterrents or sanctions
Types of Fraud/Abuse - Providers
Billing for services not rendered
Up-coding of services
Double billing/Duplicate claims
Misrepresentation of diagnosis
Unbundling of services
Unnecessary services
Inappropriate referral for financial gain
Insertion/Substitution of medicines
Unauthorised co-payments
Types of Fraud/Abuse - Members
Impersonation – a non-member using a member’s
identity
Ganging – all the family using one member’s card
Provider shopping
Illegal cash exchange for prescriptions
Frivolous use of services – drugs for sale
Ways to prevent/mitigate abuse
Policy methods – through appropriate payment
mechanisms
Each payment method has its advantages in
tackling certain types of abuse
Pre-payment methods – effective claims processing
Membership
Treatment protocols
Electronic vetting business rules
Post-payment methods
Data analysis
Clinical Audit & claims verification
Claims
Processing
Eligibility &
Membership
E-Vetting &
E-Adjudication
Provider
Payment
Paper
Claims
G-DRG
E-Claims
ICD-10
Treatment
Codes
Process, Business Rules Based Engine !!
Statistical
Data
22
Pre-Payment Methods
Claims management – Electronic & Manual
Biometric authentication at provider site – eligibility &
membership – generate claims check code
Member unique ID number checked against membership
database when claims submitted
Alert for any claims using the same unique ID number
within the last month at any provider
Check appropriateness of diagnosis against age and gender
Check match between diagnosis and treatment
Check that agreed tariffs for medicines and services have
been used
Claims Adjustments CPC v District
Post-Payment Methods
Data Analysis
Top 20 in-patient DRG’s for each specialty
Top 50 medicines diagnosed – by volume and by value
Service utilisation – OPD and IPD
Cost per claim for different provider types
Monthly value of claims per provider type per district
Month on month value of claims for each provider
Post-Payment Methods
Claims verification & Clinical Audit
Verify the attendance at the provider site
Verify the services given
Verify the medicines prescribed and dispensed
Contact members to confirm attendance,
services & medicines given
Assess the quality of care
Clinical Audit - Background & progress
• September 2009 – Claims & Clinical Audit Division
created
• January 2010 - Clinical audits commenced formally
• March 2010 – Separation of Clinical Audit Division
• June 2010 – Clinical Audit Manual developed
• December 2010 – Audit tools developed
• Biannual meeting with stakeholders to refine
process & discuss findings
• May 2013 – Clinical Audit & Accreditation merged
Clinical Audit Process
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Multi-disciplinary teams drawn from private & public sector.
Selection of auditee providers based on risk profile
Auditee providers selected from entire range of service provision
Prior notification of audit visits to ensure acceptance and results
Prior notification of clients whose folders have been selected for audit
Clients’ medical record/folders examined for:
Linkage between treatment and diagnoses/adherence to treatment guidelines
Accuracy of claims based on medicine dosage, strengths, and quantities
Appropriateness of tariffs applied for services provided
Evidence of co-payment
Exit conferences with management of provider facilities to discuss findings.
Furnishing of providers with draft report (including discussed findings, recommendations
and way forward
Opportunity for providers to dispute of findings and recommendations
Dispute resolution if required
Final report sent to providers (include claims deduction, dis-accreditation, recommendation
on quality improvement) with copies to umbrella organisations and associations
Follow-up on Recommendations through NHIA Regional Offices
Audited v Unaudited facilities
Category of findings
ERRORS
ABUSE
PROVIDERS
SCHEMES
FRAUD
CLINICAL
AUDIT
FINDINGS
QUALITY OF
CARE
Examples of fraud
• Public & Private facilities with same doctor
where 1524 patients visited exactly one month
apart
NAME
DATE (PUBLIC)
G-DRG
DATE (PRIVATE)
G-DRG
B. A.
18/10/2012
DENT18A
18/11/2012 (Sunday)
DENT18A
S. M.
24/4/2012
DENT19A
24/5/2012
DENT12A
G. B.
13/4/2012
DENT19A
13/5/2012 (Sunday)
DENT02A
N. A.
15/3/2012
DENTO2A
15/4/2012
DENTO2A
DENT02A = Surgical removal of tooth
DENT12A= Sialodectomy
DENT18A=Partial resection of the facial bones
DENT19A= Total resection of the facial bones & soft tissues
Examples of fraud
• Spurious claims – Facility puts in claims for
deliveries for patients who attended Antenatal
clinic but delivered elsewhere
• Recycling of claims from previous months to
boost numbers
• Recycling of patient details between facilities
The Way forward
Whistleblowers
Clean claims
Encourage whistleblowers and protect them by
legislation
Early reimbursement for providers with
clean claims. % tariff increase for
adherence to treatment protocols
% tariff increase
Training of health insurance staff in fraud
detection
Advocacy on
impact
Increased advocacy and sensitisation on
the impact of fraud and abuse on the
health insurance system
The Way forward
Legislation
Financial
penalties
Disaccreditation/
loss of license
Name and Shame
Pass specific health insurance fraud laws
making it a criminal offence e.g. USA
Health Insurance
Portability and Accountability of 1996
(HIPAA)
Financial penalties above repayment of
fraudulent payments
Health care provider should lose its license
with the regulatory bodies as well as
disaccreditation by the insurer
Public gazetting of fraud and abuse cases
CONCLUSION
•
Health Insurance fraud is a global phenomenon
•
It cannot be eliminated entirely but can be minimised
•
Methods to prevent fraud is insurance scheme and
country specific although there are general measures that
can apply to all
•
There will always be loopholes in the medical scheme.
•
Each time a loophole is closed, another is found.
•
Insurers need to work with providers and members if the
prevention methods are to be successful.
Thank you
Merci
Gracias
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