Whether you've chosen to outsource your health insurance needs or you've chosen to take healthcare into your own hands, you must stay vigilant and look out for the following red flags.
An Excessive Number Of Opioids & Other Prescriptions
It's no secret that opioids are in the spotlight right now. By all accounts we are facing an epidemic of opioid abuse and the government is coming down hard on medical professionals in an attempt to reign this in. Prescription drug abuse in general though, is a rapid growing problem in the US and opioids are only one example. Employer sponsored health plans are impacted significantly by the excessive costs generated due to abuse of prescription medications at the provider, pharmacy, and consumer levels. If your plan experiences an unusually high number of insurance claims involving prescriptions it definitely raises red flags and should encourage immediate investigation.
The practice of robosigning made the news not too long ago. Essentially, robosigning is when a doctor writes prescriptions or authorizes a procedure without adequately assessing the individual being treated. This could be because the doctor is simply getting lazy or because they are knowingly rushing patients through to receive insurance kickbacks. Whatever the reason, it causes misdiagnosis and repetitive, costly treatments. If your group health plan is being managed properly, you will always ensure that a medical professional is individually analyzing each health case and not just signing everything that lands on their desk.
As you know, health insurance doesn't cover every procedure. Some plans are much more comprehensive than others but even they have their limits. Sometimes, you'll get patients or doctors who misrepresent the nature of a procedure in order to obtain an insurance payment that wouldn't normally be rendered. You often see this sort of fraud with cosmetic surgery where a procedure that is purely cosmetic is presented as something that's being done for the patients health. Unfortunately, without claims review these types of procedures slip right through and drive the cost of your group health plan up.
Billing For The Wrong Type Of Worker or Service
This type of fraud includes over-billing for a service that was provided by a less qualified worker. Say you see a physician's assistant or a nurse practitioner but your group health plan is actually billed for the cost of seeing the physician. Another instance would be where a medical professional who is meant to be supervised during care actually isn’t, but the provider’s office still bills for two professionals anyway. As an example, if you're cared for by a nursing assistant with no registered nurse on duty, the provider’s office would be operating outside of medical practice regulation. This can happen during times of short staffing and the practitioner may consider it unavoidable but it is still fraudulent to include both professionals on the bill when only one was seen, even if the bill is in line with what the services would’ve normally cost. Most insurance carriers’ automated claims adjudication systems would not identify this as a “red flag” so unless someone is monitoring this type of activity for your group health plan, it can certainly drive up costs.
This would likewise extend to other abusive common practices such as itemization of services not rendered, mislabeling of higher dollar equipment than what was actually used, charging for medications administered when they were actually free pharmaceutical samples, and so on.
Addressing Fraud: Who Can You Trust?
Properly addressing health insurance fraud inevitably involves finding people and institutions that you can trust. A healthcare supply chain manager with expertise in this area will be able to pinpoint potential red-flags for fraud and connect you with trustworthy solutions to minimize your risk and ensure compliance.
At Summerlin-Roberts we leverage our expertise in cost containment to provide the best possible benefits at the lowest possible price resulting in happier employees and cleaner budgets. For more information on how to more effectively manage your healthcare supply chain please contact us today.