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Medical Fraud Waste and Abuse Explained

Medical Fraud Waste and Abuse Explained. The FBI estimates that 3-10% of healthcare spending is fraud, waste and abuse (FWA). The Centers for Medicare and Medicaid Services (CMS) divides FWA into 4 categories: 1) Mistakes: e.g. Double billing $250K infusion medication as a medical claim and a pharmacy claim. 2) Waste: e.g. Performing monthly ultrasounds on a healthy, normal-risk pregnant woman 3) Abuse: e.g. 'Upcoding' diagnoses at 'Sepsis' to be paid more when no increased intensity of medical services occurred. 4) Deliberate Fraud: e.g. A personal trainer worked out at the gym with employees and then billed the employee health plan for physical therapy claims. Insurance carriers have their own FWA departments that are supposed to stop FWA. However, historically they have not allowed outside auditing of these departments by employee health plans. Employers were just supposed to 'trust' that the carriers were catching FWA. Solution: Employee benefits consultants, employers and insurance captives hire data analytics firms to review claims for FWA in addition to the carrier. Sources: https://journalofethics.ama-assn.org/... https://www.ncbi.nlm.nih.gov/pmc/arti... https://academic.oup.com/cid/article/... https://www.commonwealthfund.org/publ... https://www.propublica.org/article/he... https://www.propublica.org/article/wh... AHealthcareZ is 200+ Healthcare Finance Educational Videos. 💥 BOOK: Check out Dr. Bricker’s Book 16 Lessons in the Business of Healing here: https://www.ahealthcarez.com/healthca... AHealthcareZ Viewers Include: Employee Benefits Professionals, HR, CFOs, Insurance Brokers, Benefits Consultants, Doctors and Nurses in Leadership Roles, Hospital and Health System Administrators, Health Insurance Carrier and PBM Professionals, Pharma and Med Device Professionals, Academic Professors and Students in Healthcare Administration and Public Health. 90,000+ Views Per Month Across All Platforms. Visit AHealthcareZ.com to Subscribe to the Healthcare Finance Video Newsletter.