Spider Webbing Technology May Trip-Up Miscreant Doctors

By Dr. David Edward Marcinko; MBA CMP™

Under the Health Insurance Portability Accountability Act (HIPAA), the U. S. Department of Health and Human Service (HHS) have operated an “Incentive Program for Fraud and Abuse Information.”

In this program, HHS pays $100 – $1,000 to Medicare recipients who report abuse in the program.

To assist patients in spotting fraud, HHS has published examples of potential fraud, which include:

• medical services not provided;
• duplicated services or procedures;
• more expenses, services, or procedures claimed for than provided (upcoding/billing);
• misused Medicare cards and numbers;
• medical telemarketing scams; and
• no-medical necessity.

Real Health Fraud Exists

There is no question that real fraud exists. The Office of Inspector General of HHS saved American taxpayers a record $32 billion in 2006, according to Inspector General Glenn A. Fine.  Savings were achieved through an intensive and continuing crackdown on waste, fraud, and abuse in Medicare and over 300 other HHS programs. To discourage flagrant allegations, regulations require that reported information directly contribute to monetary recovery for activities not already under investigation.  For the DRA in 2009, this includes the following:

• promoting state False Claims Acts (section 6032);
• enhancing the Fair and Accurate Credit Transaction Act, with “red flags” (PL 108-159); see http://www.gpo.gov/fdsys/pkg/PLAW-108publ159/content-detail.html
• employee education about false claims recovery (section 6033);
• augmenting the Medicaid Integrity Program (section 6034);
• enhancing third party recovery (section 6035); and
• “mining” medical claims for potential fraud with the help of sophisticated computer technology algorithms – called “spider-webbing” – which locate a common insurance claim denominator and then follow the thread throughout claims review. Indicators of  possible fraud include doctors charging more than peers; providers who administer more tests or procedures per patient; providers who conduct medically “unlikely” procedures; providers who bill for more expensive procedures and equipment when there are cheaper options; and patients who travel long distances for treatment.

Assessment

CMS and private companies are able to save far more money by detecting fraud before claims are paid than recovering the money after the fact. And so, a further erosion of patient confidence can be expected as CMS, and private insurers, assume the “bounty hunter” view of healthcare providers.

Conclusion

Of course, your thoughts and comments on this Medical Executive-Post are appreciated. Do you feel like the hunter; or the hunted? Tell us what you think? Do you ever – or never –  fear the spider? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Filed under: "Doctors Only", Career Development, Ethics, Health Insurance, iMBA, Inc., Information Technology | Tagged: CMS, david marcinko, DRA, Fair and Accurate Credit Transaction Act, false claims act, fragmented billing, Glen A. Fine, healthcare abuse, healthcare fraud, HIPAA, HSS, Incentive Program for Fraud and Abuse Information, Medicaid Integrity Program, medical claims mining, medicare, medicare cliams mining, spider webbing, unbundled medical billing, unbundling, www.healthcarefinancials.com | 5 Comments »