Understand the Opportunities
What are some particular weaknesses that criminals can exploit?
Electronic Claims Payment. How many times can a provider submit a variation of a claim to your system? How quickly does he find out which variations pay without notice? How much money can he take before you do notice?
Provider profiles are designed to help fairly honest providers make their practices more like the norm. For dishonest providers, it can help them fine-tune their fraudulent billing. They want to look like the norm, so you can’t find them. Looking normal doesn’t mean there is no fraud.
Service and Payment Caps help you control costs, but they can also have unintended side-effects. If claims are always right up to the limit, maybe they are being padded. A Medicaid programs was paying for Oxygen services that were billed just up to the point that prior authorization would be required. Did that many patients need the maximum allowable services but hardly any needed one unit less or enough to be prior authorized? Probably not.
Other times limits aren’t enforced well enough to be effective. One state paid almost $3 million dollars to one optician for eyeglasses that were supposedly lost or stolen. For some people they billed as many as 12 pairs of eyeglasses, despite that the limit was one pair every two years.