[CoachKandSportsguy]

The fraud does not involve the costs to the customer, nor the coverage supplied.
The fraud is in the reporting to the government for their rebates/payments from the government.

You may not see this on any parts of the payer side, nor the hospital side, nor the coverage side.

So nots not about defrauding the insurance customer as much as it's about defrauding the payer, the US government. That part is all in the coding of the submission to the government, which is not what you see nor read in any of your statements.

Coachk constantly reviews government/regulatory/ submissions for error corrections, which occurs due to human data entry, example is a 60 lb baby delivered. the decimal was in the wrong place or there was a key stroke error, true story. Most data entry points don't have logic validation steps attached, which would even more slow down the tedious data entry process.

good luck to us!

[blueash]

Advantage plans are paid a base rate by the government at a negotiated monthly rate to assume the cost of persons who would otherwise be on Medicare. But, and this is a big but... the rate is then adjusted upward if the patient population is sicker thus more likely to be costly to provide care.

UHC and I believe our local Villages Health Care are, reading between the lines, being looked at for managing the system to make it appear that they have a sicker population. The more diagnoses you can add to the paperwork the better your payment will be.

This is a very difficult judgment to make as a doctor or health care system. You get "blood work" every six months and this time your blood sugar is just above the cutoff. Always been fine before but some were at the top of normal.

Does the doctor enter elevated blood sugar into the computer as a diagnosis, or maybe pre-diabetic? Is that cheating or is it important as a reminder next time to ask about eating and maybe get an A1C?

How about the complaint that your fingers are stiff and ache in the morning but after an hour or so it self resolves? Does the doctor enter arthritis into your diagnoses as you clearly have it, or leave it out as it requires no management.

If the director of the Health Care system sends out a memo telling all the providers to be sure to enter all the issues into the diagnoses record is that good medical care or is that fraud?

[CoachKandSportsguy]

Originally Posted by blueash

Advantage plans are paid a base rate by the government at a negotiated monthly rate to assume the cost of persons who would otherwise be on Medicare. But, and this is a big but... the rate is then adjusted upward if the patient population is sicker thus more likely to be costly to provide care.

UHC and I believe our local Villages Health Care are, reading between the lines, being looked at for managing the system to make it appear that they have a sicker population. The more diagnoses you can add to the paperwork the better your payment will be.

This is a very difficult judgment to make as a doctor or health care system. You get "blood work" every six months and this time your blood sugar is just above the cutoff. Always been fine before but some were at the top of normal.

Does the doctor enter elevated blood sugar into the computer as a diagnosis, or maybe pre-diabetic? Is that cheating or is it important as a reminder next time to ask about eating and maybe get an A1C?

How about the complaint that your fingers are stiff and ache in the morning but after an hour or so it self resolves? Does the doctor enter arthritis into your diagnoses as you clearly have it, or leave it out as it requires no management.

If the director of the Health Care system sends out a memo telling all the providers to be sure to enter all the issues into the diagnoses record is that good medical care or is that fraud?

yes and no. . .

EMR keep all diagnosis for reference, though not all diagnosis are permanent, so great question, and a legitimate question.

The other issue is that limits for normal versus abnormal can change over time. Does a changed limit change the diagnosis from once healthy to now less healthy or a now has a condition? example here is healthy cholesterol limits.

The other is with EMRs, especially with research hospitals, or teaching hospitals, is that the data is regularly used for research, for healthcare improvements. The more data the better for symptom/condition analysis. Granted the analysis needs to have good stats behind it, reproducible, etc. . so does this change the payer / reimbursement amounts?

what's submitted is reimbursed, and the programmers write the data extraction programs, and most if not all data extraction programmers have zero clinical knowledge, so its easy to give minimal instructions for data extraction, and blame programmers if wrong. Coachk fights this battle on a weekly basis, as she is not clinical, but has lots of clinical reporting knowledge from data interactions with doctors and nurses, having PAs and nurses in her department.

And yes, the battle is real between IT sending data and IT sending the proper data.

good luck to us

[HappyTraveler]

Originally Posted by blueash

UHC and I believe our local Villages Health Care are, reading between the lines, being looked at for managing the system to make it appear that they have a sicker population. The more diagnoses you can add to the paperwork the better your payment will be.

Does the doctor enter elevated blood sugar into the computer as a diagnosis, or maybe pre-diabetic? Is that cheating or is it important as a reminder next time to ask about eating and maybe get an A1C?

Good comment and questions, in total.

I cherry-picked the two parts, above, because it reminded me of what a friend here in TV told me a month ago related to the local health care system mentioned.

The Doctor recommended a certain test for his lungs because of prior work he used to do. But, the patient noticed in the results report that it was stated he had smoked for 25 years. He called and inquired why that was claimed since he only ever smoked for 5 years, long ago.

It was positioned as being helpful to him as far as ensuring the claim being paid. (Iow, smooth talk so they could get the claim paid.) But, he was bothered about his health records now reflecting a very inaccurate smoking history. Hhmm...

[jimjamuser]

So, it is going to be difficult to prove fraud by UHC and our local Villages Health Care. The Advantage plans DECIDE when a patient goes home , not the Doctor. So, the Advantage plans have a vested interest in getting a patient out of the hospital as soon as possible. In a rehab facility the Advantage rehab Nurse decides when to cut off the Advantage payments, NOT the Doctor. I wonder about the complexity of the US system that depends on the insurance companies. I wonder if the National Health Care systems used by Canada and all other 1st world counties are not less complex and therefore BETTER. I understand that the US system costs much more than the Canadian system on a per patient basis. Also, the US V.A. system is much like Canada's national system and the US V.A. system keeps drug costs down.

[CoachKandSportsguy]

Originally Posted by HappyTraveler

Good comment and questions, in total.
It was positioned as being helpful to him as far as ensuring the claim being paid. (Iow, smooth talk so they could get the claim paid.) But, he was bothered about his health records now reflecting a very inaccurate smoking history. Hhmm...

exactly how fraud works, a "small" change for a guaranteed or increased payout.

I have played with several ex pros in several sports, alumni/fund raising/pickup, and they all know the rules very well and they all know how to cheat, or push the boundaries to think they have an edge. Whether they cheat or not is an individual decision, not a generalization. A college friend was a sailing olympic aspirant, and he built a boat (Finn) pushing to all the edges of rules limits on boat design. The result was a failure due to too thin of fiberglass which subsequently leaked through very microscopic holes. . he changed classes afterwards. . as he no longer had a perceived edge.

Cheating comes in many forms, and it's all relative, some look like racial profiling, others look like white privilege, depending upon the situation and your point of view. The greater the prize, the chances are increased. For career survival, the chances are increased.

So once you start looking and noticing, the more you will find more easily.

NFL referee head has admitted to such as the NFL is a private sports entertainment conglomerate, and success depends upon desired outcomes. Sometimes it works in their favor, and if you watch closely, you can see it in real time. . especially when the network rules analyst who explains the expected ruling is clearly wrong.

[Aces4]

Originally Posted by HappyTraveler

Good comment and questions, in total.

I cherry-picked the two parts, above, because it reminded me of what a friend here in TV told me a month ago related to the local health care system mentioned.

The Doctor recommended a certain test for his lungs because of prior work he used to do. But, the patient noticed in the results report that it was stated he had smoked for 25 years. He called and inquired why that was claimed since he only ever smoked for 5 years, long ago.

It was positioned as being helpful to him as far as ensuring the claim being paid. (Iow, smooth talk so they could get the claim paid.) But, he was bothered about his health records now reflecting a very inaccurate smoking history. Hhmm...

Then is it the Drs. who are submitting altered claims to assist their patient in getting coverage or the insurance company who bases claims per the information sent to them?

Good luck all right, for the sorting out of the fine details...

[HappyTraveler]

Originally Posted by Aces4

Then is it the Drs. who are submitting altered claims to assist their patient in getting coverage or the insurance company who bases claims per the information sent to them?

Smile...no, that was the smooth talk. The health system in question "adjusted" his records that way so THEY could get paid.

Don't expect charitableness from any entity where money is involved. Most often, it is their wallet they are thinking about.