The World of Coding and Medical Billing Fraud – Part 1

by Andrea Vieten
Health care billing statement.
Header Photo: GettyImages

According to the National Health Care Anti-Fraud Association (NHCAA), losses from health care fraud exceed tens of billions of dollars each year. Some estimates assign 3% of total health care expenditures to fraud, while other government and law enforcement agencies estimate that approximately 10% of the costs can be attributed to fraud.

As with any insurance fraud, medical billing fraud translates into higher premiums for consumers, as well as reduced benefits or coverage. It also has other side effects: for instance, as the perpetrators of fraud increase their presence and attempt new schemes, insurance companies become more concerned and implement more checks and balances to try to stop the fraud. This results in more hurdles for legitimate providers to overcome, delaying payment for bills that should be paid, and sometimes the patient receives statements with late payments due.

Health insurers deploy medical bill review companies to assess medical bills. By repricing and disallowing undocumented or incorrectly documented items, medical bill review companies save money for health insurers. But prevention of medical billing fraud requires more sophisticated tools and methods.

With RiskShield, INFORM aims to detect and prevent medical billing fraud, which goes beyond the scope of medical billing review companies. Our medical billing and encoding experts, Tami Rockholt and Mike Fossey, explain the three concepts RiskShield uses to identify additional savings and how health insurers can benefit from RiskShield. The result is two-fold: RiskShield identifies bills that do not conform to commonly understood medical billing rules. These bills can be directly denied using standard letters and result directly in savings. On the other hand, RiskShield detects suspicious claims and providers and offers data and information for the subsequent investigation.

This video marks the beginning of a series of videos where Tami and Mike will take us into the world of encoding issues and medical billing fraud.

Video Notes

Brief introduction (0:00)

Medical billing fraud introduction (0:38)

How medical bill review companies work (1:10)

How does RiskShield detect medical billing fraud (1:20)

How can insurances benefit from RiskShield (2:23)

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About the author

  • Andrea Vieten

    As a Senior Business Consultant at INFORM GmbH, Andrea Vieten has been responsible for managing global implementation projects in the financial industry. With more than 10 years of experience, she has consulted and guided many financial institutions to the successful implementation of intelligent decision systems in the areas of risk, processes and compliance.

    All posts by this author

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