Healthcare fraud and abuse detection

What is health care fraud? It’s a type of fraudulent and criminal activity related to health care claims in order to make a profit. Healthcare fraud can be done on the part of the provider (i.e. the hospital or the doctor or even the medical staff involved) or by the client or patient. Most common type of fraudulent activity in healthcare activities is providing fake bills in order to get reimbursement either from employer or directly from the insurance company. Due to the level and dept of penetration there is a huge loss of revenue detected world wise. There are plenty of opportunities for fraud to happen in the healthcare industry but also plenty of methods for detecting it. Contemporary healthcare is a multilayered and fragmented enterprise composed of competing and conflicting payers and participants, each with ample circumstances and motives to commit fraud. This climate presents both tremendous opportunities and significant challenges for auditors in the healthcare industry. The unfortunate reality of fraud is that once an asset is stolen, it is gone. The moral is that prevention is key. Barring major changes in the healthcare delivery system, however, the main thrust of ensuring payment and service integrity will continue to be on the back end of the process. This is where the auditors come in. Healthcare fraud is an evolving concept that responds to antifraud pressures by branching out in new directions or developing additional defenses against detection and new means of concealment. Auditors should be alert to these emerging issues and attuned to healthcare market trends with shifts in risks, opportunities, regulations, and business practices.  It is important to remember that, in evaluating evidence, not only must auditors exercise professional skepticism; they must also be prepared to recognize potential fraud. Information technology can be the answer to detecting such fraudulent activities in the healthcare industry. There are many software packages and technology trends which are up coming and should provide an answer to at least lessening such activities, if not completely stopping them. Automated coding software can be studied to and recommend best practices for the prevention, detection and prosecution of healthcare fraud. As the healthcare sector embraces electronic health records to reduce medical errors and improve cost-effective delivery of care, these same technologies have the potential to prevent and detect healthcare fraud. The major technology approaches from the major players are just very expensive. The cost of such investments has been very difficult for many companies to get approved. And most products that are good at spotting such frauds are mostly retrospective. And it's much harder to get that money back after the check's been sent. It would be beneficial if the programs could better address fraud prospectively, but then they face trouble from states with prompt payment laws and HIPAA transaction standards. Clients can have difficulties in aggressively attacking provider fraud because they need to maintain good relations with their provider networks. Thus, all we need is the complete cooperation of all parties together with the right tools to help us curb the healthcare frauds!