With an estimated $700 billion or more in health care waste each year, there are definitely some fraudulent practices to be on the watch for. One of the biggies is medical coding. When scouring those health claims, be sure the appropriate HCPCS codes and AMA modifiers are used and that they represent the type of care performed. Watch for upcoding and unbundling practices, too. This means making sure you aren’t billed for a higher level of service than what was actually received and that items that are supposed to be grouped together aren’t individually charged.
Two more areas of health care fraud to carefully review are hospital stays and surgeries. Monitor your claims to be sure the proper staff members are listed by procedure and check that the right modifiers are noted for anesthetics. Do any charges on the hospital bill seem inflated or out of line? Follow up.
A few of the other trigger points to examine are experimental and other high-cost treatments like dialysis, chemotherapy and transplants. Because these are often among the most expensive services today and new advances are constantly being introduced, it’s important to review all related claim charges for accuracy.
It may seem like a lot to watch for when those claims come in, but taking the extra time to scrutinize them is always worth it.