FRAUD SCHEMES of [Fewer] Medical Providers

[TOP TEN IN HEALTH CARE]

Sponsor: http://www.CertifiedMedicalPlanner.org

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By Dr. David E. Marcinko MBA CMP®

  1. Billing for services not rendered.
  2. Billing for a non-covered service as a covered service.
  3. Misrepresenting dates of service.
  4. Misrepresenting locations of service.
  5. Misrepresenting provider of service.
  6. Waiving of deductibles and/or co-payments.
  7. Incorrect reporting of diagnoses or procedures (includes unbundling).
  8. Overutilization of services.
  9. Corruption (kickbacks and bribery).
  10. False or unnecessary issuance of prescription drugs.

[Source]: Charles Piper; CFE CRT January/February 2013 ACFE

Related: https://medicalexecutivepost.com/2020/10/01/healthcare-fraud-and-abuse-costs-and-cases-rose-in-2019/

More: https://medicalexecutivepost.com/2017/05/03/combating-healthcare-fraud/

Update: https://medicalexecutivepost.com/2021/04/24/fraudsters-phishing-for-physician-signatures/

ASSESSMENT: Your thoughts are appreciated.

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TEXTBOOK ORDER: https://www.routledge.com/Risk-Management-Liability-Insurance-and-Asset-Protection-Strategies-for/Marcinko-Hetico/p/book/9781498725989

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PODCAST: Healthcare Artificial Intelligence, Machine Learning and Natural Language Processing

PODCAST ON UnitedHeathcare Group Annual Report

Dr. Eric R. Bricker, Internist in Dallas, TX | US News Doctors

By Eric Bricker MD

An Annual Report from UnitedHealth Group Says United is Going Drive Growth by Using AI and Machine Learning to 1) Help High Risk Patients, 2) Assist Patients with Multiple Chronic Diseases, 3) Partner with Providers and 4) Be More Patient-Centric.

Some More Concrete Examples of How AI and Machine Learning Can Be Used in Healthcare and Health Insurance Are:

1) Better Underwriting of Risk

2) More Highly Focused Prior Authorization

3) Cherry-Pick the Individual Health Insurance Market

However, the Execution of AI’s and Machine Learning’s Finding Requires Human Behavior Modification–an Almost Impossible Task for Any Insurance Carrier to Accomplish Because of Their Low Credibility with Patients, Doctors and Nurses. Without Credibility and Trust, All the AI and Machine Learning in the World Will NOT Change People’s Behavior.

PODCAST LINK: https://www.youtube.com/watch?v=c9knoA30sD4

Disclaimer: Dr. Bricker is the founder of Texas Family Insurance – an independent insurance agent that sells Oscar Health.

ASSESSMENT: Your comments are appreciated.

THANK YOU
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