Transcript Provider Perspective, Dr Manoj Gupta

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
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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.
THANK YOU