Let’s talk about Fraud Waste and Abuse (FWA)

First we need to understand the meaning of those words.

FRAUD = is an act committed knowingly, willfully, recklessly, or intentionally to obtain reimbursement or personal benefits by misrepresentation or deception, usually represented in the form of false statement.

WASTE = can be intentional or unintentional and includes careless expenditures, consumption, management, use or squandering resources. It also includes incurring in unnecessary costs as a result of an inefficient practices.

ABUSE = is the lesser offense. Is not an intentional misrepresentation and includes excessive charges, improper billing practices, providing and billing services that do not meet the standard of care and billing for unnecessary services among others.

Many private and government organizations are united to fight FWA. Organizations like:

ü  Private Health Insurance companies

ü  CMS = Centers For Medicare & Medicaid Services

ü  OIG = U.S. Office of the Inspector general

ü  DOJ = U.S. Department of Justice

ü  HHS = U.S. Department of Health And Human Services

ü  NHCAA = National Health Care Anti-Fraud Association

ü  MFCUs = Medicaid Fraud Control Units

ü  FBI = U. S. Federal Bureau of Investigations

ü  HEAT = Health Care Fraud Prevention And Enforcement Action Team

ü  GSA = General Services Administration

ü  Individual States agencies

All of them are developing new ways to detect, prevent and prosecute FWA schemes by:

Ø  Developing new technology (software’s, apps etc.)

Out there are many software waiting for you to make a billing error. Most of them look for billing patterns and compare them among other peers. They also look for unnecessary procedures. Others software look for coding edits. Among others programs and software.

 

Ø  Beneficiaries referrals

Most insurance companies including Medicare send monthly evidence of benefit letter (EOB) to their members, to let the member know which claims the provider submit and the amount billed. This form of FWA prevention improve member referrals because if they notice any irregular information they reach out to the insurance FWA hotline.

Ø  Provider HELP

By providing education most of the insurers approach their providers and give them opportunities to improve their practices. No one like delay in payments or recoupments.

 

Ø  Screening processes

This processes include claims and medical record screening. By this method insurers compare and validates if the information submitted on the records supports the procedures billed. They also look for billing services that doesn’t meet the standard of care and not medically necessary services.

Ø  Comprehensive plans

Each agency develop a comprehensive plans according to their needs.

 

Is a challenge fighting FWA as many individuals and organizations are continually altering schemes while developing new ones to remain undetected. For those who are doing wrong things on purpose the road ahead is really bumpy. Just have in mind that the government assign additional $350 million over 10 years to boost anti-fraud efforts. Also private insurers invest high amounts of money and are constantly developing new ways to end FWA.

Is a challenge for those providers who do it the right way because they get caught up and end up losing money.  To those who really care about their patients and are getting investigated due to billing errors because the lack of experience of their employees we are here to HELP.