KING OF PRUSSIA, Pa., Aug. 11 A recent report on CNN pointed out that only 40 pages of the more than 1,000-page House Healthcare Reform Bill addresses fraud, which by various estimates is a $75 billion to $300 billion a year problem.
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An article published in a recent issue of Health Plan Week reported that the Blue Cross and Blue Shield Association's national anti-fraud department claimed that anti-fraud investigations in 2008 turned up $350 million in savings, a 43 percent increase from the previous year.
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In commenting on the CNN and Health Plan Week stories, David McSweeney, COO of Healthcare Data Management, Inc. (HDM), a leader in audits and analytics for self insured health plans, said, "I'm glad to see health insurance fraud getting the attention it deserves. We've been battling fraud and honest mistakes since 1992. There isn't an approach to fraud that we haven't seen, and there's one irrefutable fact we've learned -- retrospective audits can be ineffective in spotting health insurance fraud before it becomes a big problem."
The Health Plan Week article claimed these principal types of fraud: 1) providers who are doing things like upgrading to gain higher reimbursements for services, 2) billing for services not rendered, 3) "phantom" providers or identity theft and 4) prescription drug scams.
The same article reported that a recent white paper by the National Health Care Anti-Fraud Association (NHCAA) estimated that as much as 10% of U.S. healthcare costs -- ($224 billion) in 2007 alone -- was fraud. The NHCAA is proposing that reform legislation include more information sharing between government and private health insurers to help solve this problem.
"I'm sure that information sharing would help," McSweeney said. "However, we believe there's no substitute for catching the scammers -- whether they be providers or plan members or friends of members -- than for plan sponsors to institute an ongoing system of surveillance by an independent third party.
HDM has launched a service called BenefitsWatch, which enables a self-insured company to provide its clients with quarterly reports based on monthly data feeds of paid claims from insurers. "BenefitsWatch catches fraudulent actions before they become big, often unrecoverable problems," McSweeney explained. "It can actually link Rx and Medical claims to track prescriptions back to the appropriate diagnosis, if there is one."
With BenefitsWatch, HDM analyzes 100 percent of supplied claims in a client customized data warehouse, against "exceptions" or deviations from plan documents. BenefitsWatch also applies HDM's own proprietary benchmarks to analyze three critical areas of plan performance... compliance, budget and cost and utilization.
For more information about HDM and BenefitsWatch, visit www.hdminc.com.
SOURCE Healthcare Data Management, Inc.
