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PubMed1996

Health care fraud control: understanding the challenge.

The study summarized here examined the fraud-control apparatus currently used within the health care industry, and assessed the assumptions, policies, and systems that constitute the industry's current approaches to fraud control. The objective was to develop a better understanding of the strengths and weaknesses of existing approaches. Since 1992, with Health Care Reform under debate, the issue of health care fraud has received unprecedented legislative and administrative attention. Nevertheless disturbing and somewhat surprising lapses in control persist. The fraud problem shows no sign of abatement. Background knowledge of the health care fraud issue was derived from literature searches and from four years of interaction with concerned public and private organizations. Fraud control systems, policies and procedures were examined in detail at eight field sites, representing a cross section of private, not-for-profit, and public programs. The National Institute of Justice funded the study under grant number #94-IJ-CX-K004. This study finds the science of fraud control scarcely developed and little understood by industry practitioners. Academia has paid little attention to the problem. Within the health care industry, the task of fraud control is complicated by the social acceptability of insurers as targets, the invisible nature of most fraud schemes, the separation between administrative budgets and "funds", the respectability of the health care profession, and the absence of clear distinctions between criminal fraud and other forms of abuse. Existing approaches to control are more effective in controlling billing errors, overutilization, medical unorthodoxy, and other forms of abuse than in dealing with criminal fraud. The complexity of the fraud control challenge is seriously underestimated by the health care industry Existing control systems are not targeted on criminal fraud and cannot be expected to control it. Scientific measurement of the fraud problem is a prerequisite effective control.

Crime↗
PubMed1997

Effects of the Health Insurance Portability and Accountability Act of 1996.

As small business employers, physician group practices will be subject to provisions of the Health Insurance Portability and Accountability Act of 1996 related to coverage guarantees. The act prevents currently insured individuals from losing coverage if they change jobs, limits insurance exclusions related to preexisting conditions, and requires insurers that offer small group coverage to make such policies available to all small employers. While the act's coverage guarantees may help group practices to attract good employees who formerly feared losing their coverage if they changed jobs, it also is likely to increase administrative costs, lead to premium increases, and limit to the choices for practices that must shop for health plans. Practices planning to purchase health insurance can ensure that they receive the best coverage possible by carefully comparing policy features and the claims services potential insurers provide.

Employee Incentive Plans↗
PubMed1998

Payers required to adopt standardized electronic claims processing.

The Health Insurance Portability and Accountability Act of 1996 requires most claims payers to support electronic claims processing and uniform national standards for code sets and identifiers to streamline healthcare administration. The law will penalize payers that do not support the standards and are not prepared to conduct business electronically by the year 2000. Many providers may qualify as claims payers and, thus, will be subject to penalties if they do not adopt EDI for the transactions required by the Act. Providers also will have greater opportunity to eliminate paper, speed claims payments, and cut administrative overhead. Both providers and payers will have new guidelines for privacy and confidentiality, and violation of these guidelines will result in significant penalties. Consequently, all providers should become familiar with the legislation and evaluate their EDI strategy in light of new opportunities and responsibilities.

Chronology as Topic↗