what are the best ways to diagnose fraud & forgery in medical claims?

Fraud in medical billing and coding costs taxpayers and medical providers millions of dollars annually.

Healthcare providers and medical billers both have the ability to commit fraud by knowingly reporting codes and procedures that weren't performed. Honesty and integrity are key elements to a good medical biller, and good medical billers play a key role in preventing fraud.

Using the medical billing and coding standards to their advantage, medical billers create uniform checklists to follow as they process claims. Anomalies in these checklists help medical billers spot fraud before any occurs.

Medical billers and coders can work together to strengthen this process further by having one person submit the claims and a second person double-check the claim and post payments or adjustments

The more people that review that claim, the more accurate the claim will be.

ans: To avoid Fraud and Forgery, all you have to do scrutinize to what's happening on your account to prevent different types of medical billing fraud at the same time Forgery in your part. Eventually, once you apply  the corporation will process in a wrong procedure. Your account might experience upcoding that  assigns a diagnosis or procedure that costs more or has a higher rate of reimbursement than is medically necessary; Downcoding that gives the patient a lesser diagnosis and sometimes shows fake patient improvement. This can allow for extended hospital stays or allotment of benefits for recovery that would not otherwise be given;  Separating procedures that is the process of separating the procedures performed at one time into separate treatments or separate visits;double billing that is the practice of billing for the same treatment or visit more than once, even if the patient wasn't seen and unnecessary treatment are treatments or services that are provided to the patient which are not medically necessary.   Try to follow up and verify your account! GOD BLESS              

identification copy of patients will be attached with ucaf. if any thing is problem means reception is the responsible for that problem. because receptionist have to look patients who belong to medical insurance card.

Fraud involves intentional deception or misrepresentation intended to result in an unauthorized benefit. An example would be billing for services that are not rendered. Abuse involves charging for services that are not medically necessary, do not conform to professionally recognized standards, or are unfairly priced. An example would be performing a laboratory test on large numbers of patients when only a few should have it. Abuse may be similar to fraud except that it is not possible to establish that the abusive acts were done with an intent to deceive the insurer.

This is where a medical biller play a major role. Adjudication of the claims as per insurence company norms will come into picture. Automated systems will fail to identify this and certainly insurance companies will loose the amount in big figures. One can refer to the claims ratio which will fetch more light on this. It would also require the analytical aspect of it.

 

there are possibility to make fraud medical claims, it is easy to get a copy of insurance and civil ID of each insured member from their previous visit, other supporting documents such as investigation results and medical summary/claim forms can be created easily, the best way to prevent is use an finger print machine at health care provider to confirm the patient ID, or  keep sending SMS alert to every insured member if healthcare provider used their insurance card for checking online eligibility, in case insurance company/payer received any bills for any insured member, send details of the claims by email. let patient know that some claims are prepared under his insurance coverage.. 

after all some patients/insured members are bringing their friends and relative to examine under his card,, in this case only physician must confirm the patient ID before examining..