Medical Billing Fraud and Abuse... How to Stop It. Hospital and Doctor fraud and abuse accounts for 310% of all healthcare spending.

This means, a company with 1,000 employees is spending $300K $1M per year as a result of fraud and abusive billing practices.

Doctor and Hospital may engage in 'Upcoding' to maximize reimbursement. They do not view changing codes to maximize reimbursement as 'Upcoding,' but there is a fine line between correctly coding and 'Upcoding.'

Insurance companies often deny claims and require prior authorization. However, these practices do not stop fraud and abuse. Often the denials and prior authorizations miss the fraudulent claims and abusive billing practices.

Solutions include: 1) Become SelfFunded and review your own claims, 2) Move away from FeeforService to nonclaimsbased healthcare services such as an onsite or nearsite clinic or direct contracting.

Sources:
https://journalofethics.amaassn.org/...

https://www.ncbi.nlm.nih.gov/pmc/arti...

https://academic.oup.com/cid/article/...

https://www.commonwealthfund.org/publ...

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