Fraud is nothing new, but that doesn’t mean it never changes. Certain parts of the ICD-10 implementation create obstacles for fraud detection.
These are a handful of healthcare schemes to be aware
1. EHR-related fraud.
As EHR systems become more prevalent, there are increasing issues with fraud related to auto-population. Trussell notes that some systems allow auto-population to check or uncheck boxes related to what the clinician did to make a diagnosis. Because some software doesn’t include audit trails, it’s impossible to tell who checked/unchecked the box.
2. ACA-related fraud.
Trussell says fraud investigators must be vigilant about copycat HealthCare.gov sites and possible medical identity theft from those sites.
3. Test-related fraud.
There are two potential fraud areas here. One is expensive genetic tests that aren’t required for diagnosis. The other is testing companies targeting outside the clinical area (e.g., signing people up at shopping malls).
4. Sleep-study fraud.
Trussell says Medicare Part B medical billing for these services rose 40% in the last five years and warns healthcare companies to pay close attention to those claims.
5. Medicare Part B schemes.
Emerging trends include heart stents that are medically unnecessary and cosmetic procedures billed as precancerous lesions.
6. COVID-19 Fraud
Of course, fraudsters are taking advantage of a global pandemic to scam individuals. These schemes ask for personal information and offer COVID-19 tests, HHS grants, and Medicare prescription cards in in return. HHS’s Inspector General warns people to be cautious of requests like these and to report them to the Human and Health Services tipline.
As private medical practices transition to medical billing software, they must be cognizant of the the latest fraud schemes and be sure the software they select aligns with rigorous medical billing processes to avoid unnecessary risk.
