Fact Check: Fast Facts about Fraud
Posted by The Campaign on January 28, 2010 at 10:14 AM
$60 billion: the estimated amount of fraud within Medicare each year
$17 million: the average annual amount of money saved by each health plan’s anti-fraud operations
$7.60: the average amount of money a health plan returns to the company and policyholders for every one dollar invested in anti-fraud operations – which keeps health care costs down for businesses and working families
Source: Anti-Fraud Management Survey Report for 2007 by the National Health Care Anti-Fraud Association
Health care fraud leads to higher costs for businesses, workers, and families. The overwhelming majority of health claims are legitimate and paid on-time, but for those that might be fraudulent, health plans use a variety of measures to prevent and detect them, including:
· Education and awareness campaigns: Policyholders, providers, and the public are encouraged to report any suspected fraud through telephone hotlines and websites.
· Commitment to safety: Health plans ensure their networks include only credentialed providers to protect consumers from unlicensed providers.
· Cross-disciplinary teamwork: Employees from a variety of backgrounds investigate potential fraud and collaborate across a health plan in order to weed out only potentially fraudulent claims for investigation.
· Communications with policyholders: Policyholders are encouraged to monitor their explanation of benefit forms for medical services they did not receive and to report known instances of health fraud.
· Monitoring and collaboration: Working with external law enforcement agencies at the state and federal levels, health plans prevent and protect consumers from fraud.
· Use of sophisticated software: Analyzing claims data helps predict potential fraud and weed out the “outliers” for further investigation, allowing effective and efficient investigation of the few claims with potential for fraud.
· Commitment to professional excellence: Health plans require credentialing and ongoing annual training for their staff dedicated to investigating health fraud in order to keep up with changes in technology and laws and effectively weed out health fraud and abuse.
