Build Fraud Control Into Your Policies

Build Fraud Control Into Your Policies

Healthcare Fraud Control Articles

When we create healthcare policy, we spend months thinking about how the policy will change the behavior of providers and patients. Ninety-nine percent of the time we’re thinking about honest providers and patients. But what about the people who aren’t honest? Are we handing them an easy opportunity for fraud?

When we make policy, we may not be thinking about fraud, but I guarantee that some unscrupulous providers and patients are. From the moment our new policies are enacted, somebody starts scamming the new system. It may take us months or years to figure out the scam, by which time, the fraudsters have moved on to new scams. If we think about fraud before we implement new policies, we can avoid much of this problem.

New policies increase our risk of fraud, because they create new loopholes, and disrupt current payment and utilization patterns. If you see a spike in spending after a policy change, it might be hard to tell whether it was an intended result of the change or the result of a scam.

Even policies that are intended to curb fraud and abuse can result in a shift of abusive behavior or even an increase in abuse. For example, if you find that some providers have been prescribing a drug without treating the patient for a diagnosis that requires the drug, you may decide to require prior authorization for the drug.

How are you going to measure the effectiveness of this policy? As soon as you announce the new rule, physicians who were cheating are going to realize that they better bill for office visits that substantiate the patient’s need for the drug (and your policy probably told them exactly how to do it). Now fraudsters look just like legitimate providers, and you are paying more than you were without the policy. Your prior authorization team has more work to do, and legitimate providers have to jump through extra hoops. But if you’re only measuring the amount paid for prescriptions without a supporting diagnosis, it looks like the policy was a success.

So how do you protect yourself? Have your fraud experts review new policies to find loopholes and incentives for fraud. You can either alter the policy to avoid the problems or create measures, surveys, claims edits and procedures to catch the fraud before it happens.