Fraud prevention: Do you know what the criminals are up to?

Jim O'Neil
Do you know the most recent plan criminals have taken to nab millions of dollars from an insurance company? Experts say that staying current on fraud news is one of the most significant steps payers can take to help prevent fraud from destroying their organization.

"The most effective detection method is being aware of fraudulent scams in the industry and staying on top of new trends," Gary Crispens, director of special investigations unit at Blue Cross and Blue Shield of North Carolina (BCBSNC), told FierceHealthPayer in its newest eBook, Payer Strategies to Prevent & Detect Fraud.

Health insurance fraud costs roughly $234 billion a year, but payers that implement anti-fraud programs can save anywhere from $5 million ($2.70 per enrollee) to $300 million ($3 per enrollee), according to America's Health Insurance Plans data. That's nothing to shake a stick at, which is why anti-fraud programs are vital to payer success.

Many payers already have fraud prevention programs established, but most still use the pay-and-chase method that attempts to recoup money after claims are already paid. Experts suggest payers would benefit from including advanced health IT and data analytics to chase down potential fraudsters. And the incentive to update anti-fraud activities are clear; fraud recoveries return about 20 cents on the dollar, while avoiding paying fraudulent claims provides dollar-for-dollar savings.

WellPoint, for example, has applied a prepayment review method to help thwart fraud from ever occurring. The insurer's program requires problem providers file paper claims that WellPoint's clinicians and coders then process with special attention, Alanna Lavelle, director of investigations for southeast and central regions, says in the eBook.

Meanwhile, BCBSNC has found success using "state-of-the art fraud detection software" that mines claims payments to identify areas needed for additional investigation. With it, the insurer can identify outliers using a variety of analytics based on payment data, utilization and billing patterns, the provider's practice specialty profile and mathematical formulas, Crispens explains in the report.

And with the ICD-10 compliance deadline coming in 2014, payers could be facing some new and improved fraudulent activity because the code's complexity and volume could shield unscrupulous providers. That's why Blue Cross and Blue Shield of Illinois (BCBSI) is scrutinizing three key areas to ensure it doesn't get caught unprepared. The insurer is assessing how to leverage ICD-9 information to identify codes with the greatest fraud risks; accommodating providers' approaches to clinical coding, medical records and billing systems; and training external-facing staff to identify provider problems. "With proper preparation, planning, communication, testing and evaluation methods in plans, health plans, providers and vendors can greatly mitigate risk," says Sydney V. Ross-Davis, BCBSI's medical director of special investigations.

For even more tips on improving payer fraud prevention and detection, including advice from the FBI Health Care Fraud Squad, tips on how to work with local law enforcement and recommended steps to prepare for federal fraud investigations, be sure to check out the eBook, Payer Strategies to Prevent & Detect Fraud. Your organization's wallet will thank you. -Dina (@HealthPayer)

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