Hello kms,
Interesting question. Thanks for asking.
I searched for - health care losses incorrect claims - and found the
following:
And article at http://www.osc.state.ny.us/press/releases/sept00/92500.htm
entitled "McCall Audits Result in Recovery of $42 Million in Misspent
Medicaid Dollars, But Problems Remain" shows the following:
"More than $42 million of $90.5 million in incorrect Medicaid payments
identified in previous McCall audits has been recovered by the
Department of Health (DOH). However, millions of Medicaid dollars
continue to be misspent because of uncorrected weaknesses in DOH’s
computer billing system, according to audits and reports released
today by State Comptroller H. Carl McCall...
...McCall’s annual on-going audit of the MMIS system identified $32
million in improper Medicaid payments to providers in FY 1999-2000.
The majority of errors were for inpatient hospital care that had
already been paid or was not billable to Medicaid. Nearly $9 million
was recouped during the audit process, and McCall urged DOH officials
to work to recover the remaining $23 million. Auditors also prevented
millions of dollars in additional overpayments when they spotted a
clerical error in which a DOH rate change for hospital daily
rehabilitation costs was listed as $11,106, rather than $1,863. DOH
corrected the error. "
There is more detail and backup information at this page.
An interesting report by the United States General Accounting Office -
The Honorable Charles E. Grassley,Ranking Minority Member,Committee on
Finance,U.S. Senate says in part:
"In addition to losses due to fraud, the Department of Health and
HumanServices' OIG has reported that billing errors, or mistakes, made
by healthcare providers were significant contributors to improperly
paid health care insurance claims. The OIG defined billing errors as
(1) providing insufficient or no documentation, (2) reporting
incorrect codes for medical services and procedures performed, and (3)
billing for services that are not medically necessary or that are not
covered. For fiscal year 2000, the OIG reported that an estimated
$11.9 billion in improper payments were made for Medicare claims."
This report is available here: www.gao.gov/new.items/d01818.pdf
Trying to narrow the search down to more specific studies or reports,
I searched healthcare OR hmo OR provider +losses +error OR incorrect
+forms OR claims . Included in the results were the following:
A report by the Honorable June Gibbs Brown, Inspector General, U.S.
Department of Health and Human Services, in Testimony Before the
Sucommittee on Health of the House Committee on Ways and Means on
July 17, 1997 says in part:
"In view of Medicare's 38 million beneficiaries, 800 million claims
processed and paid annually, complex reimbursement rules,
decentralized operations, and health care consumers who may not be
alert to improper charges, the Medicare program is inherently at high
risk for payment errors. Medicare, like other insurers, makes payments
based on a standard claims form. Providers typically bill Medicare
using standard procedure codes without submitting detailed supporting
medical records. However, Medicare regulations specifically require
providers to retain supporting documentation and to make it available
upon request. Because of the high risk in health insurance
reimbursement and its dollar magnitude in relation to financial
statement impact, i.e., $168.6 billion in Medicare fee-for-service
claims, we embarked on a comprehensive review of claims expenditures
and supporting medical records...
We estimate that during FY 1996 net overpayments totaled about $23.2
billion nationwide, or about 14 percent of total Medicare
fee-for-service benefit payments. These improper payments could range
from inadvertent mistakes to outright fraud and abuse. We cannot
quantify what portion of the error rate is attributable to fraud.
Specifically, 99 percent of the improper payments were detected
through medical record reviews coordinated by the Office of Inspector
General (OIG) in conjunction with medical personnel. When these claims
had been submitted for payment to Medicare contractors, they contained
no visible errors."
This report is available at
http://waysandmeans.house.gov/health/105cong/7-17-97/7-17brow.htm
In a report by a law firm, Damon and Morey at
http://www.damonmorey.com/pubs/winter2000.html on disclosure and
health law says in part:
"Billing errors, overpayments and misconduct can occur in any health
care organization. Historically, such problems were ignored by the
health care organization, or worse, covered up. Ignorance of
disclosure issues and non-disclosure of possible violations are not
wise in light of the government's current anti-fraud efforts. Health
care managers are receiving more reports of billing and reimbursement
problems as the government increases its scrutiny."
Further searching for - health insurer OR provider incorrect paid
claims -fraud - uncovered the following sites:
Cost Cutting Analysts at
http://www.costcuttinganalysts.com/audit/health.htm claim:
"Health Insurance Claims Review
CCA's program is specifically targeted to self-insured plans; third
party administered plans; HMO's and other managed care plans.
Our focus is payment errors and the pursuit of full recovery of claim
overpayments.
As reported by the American Health Information Management Association;
"... this is a problem that results in annual payments of more than
$20 billion in incorrect claims."
Adding overpayment to my search terms found:
Physician's New Digest at
http://www.physiciansnews.com/law/502artz.html discusses the problem
of billing and provider misidentification:
"Provider misidentification has become the subject of federal
enforcement actions. The FBI and Department of Justice have launched
investigations, Medicare Carriers have made overpayment refund demands
and commercial third party payors have imposed sanctions as a result
of provider misidentification.
Provider Misidentification Problem
A remarkable number of health care practices across various
specialties and professions (in many jurisdictions) bill for services
under one doctor's name and identification number when another doctor
actually rendered the services. This practice, whether inadvertent or
intentional, is not correct."
They go on to show that financial loss is possible under these
circumstances:
"If, however, the payor is a gatekeeper managed care organization or
HMO, which has strict credentialing requirements limiting the number
of providers who can participate and the product has no out of network
benefits, misidentification of the provider who actually rendered the
services results in reimbursement that neither the doctor nor the
patient were authorized to receive."
The Rational Observer discusses insurance company scams related to
billing errors and losses at
http://www.rationalobserver.com/insurscam.htm and says in part:
"...using non-medical examiners to evaluate and validate medical
claims reduces insurance costs. Further by creating duplicate billing
through the insurance company computer systems, insurance companies
can now make it appear as if providers were defrauding the insurance
company. An additional benefit for these companies is that this
procedure allows the insurance company to report a continuing
increased loss in income to the state insurance commissioners.
Thereby, getting their requests for state insurance waivers looked
upon in a more favorable light."
An interesting view on a possible cause of these problems.
I hope the information above will serve as credible sources for you
and show that large losses are incured by health insurers due to
computer and human error. Do ask for clarification if any of the above
is unclear.
Best regards,
-=clouseau=- |
