The Problem With ICD-10 and Fraud Dectection



icd10 healthcare insurance fraudDetecting healthcare insurance fraud takes the work of vigilant investigators as well as help from the investigators you don’t hear about.  Namely computer systems running complex algorithms looking for slight deviations and discrepancies in data and variables.

Variables such as the average cost of medical procedures, dollars paid per patient and the average number of visits per year.

The impending arrival of ICD-10 (International Classification of Diseases) will present a challenge to these algorithms.  The result will make the algorithms less efficient and blur the lines between coding mistakes and legitimate healthcare fraud.

The statistical anomalies that were learned in the previous system will take approximately 18-24 to relearn under IDC-10.  This will allow some fraudulent activity to go undetected or under the radar until new data is collected. As a result many claims may be flagged as ‘fraudulent’ and delay payments until the new ICD-10 code set is learned.

Some of the most common types of fraud are:

  • Billing for services that were never provided
  • Billing for services that were more expensive than those actually provided
  • Performing unnecessary services
  • Misrepresenting treatments that were non-covered as medically necessary
  • Providing false diagnoses
  • Unbundling procedures so that they appear separate
  • Overbilling a patient his or her co-pay
  • Waiving a patient’s co-pay while overbilling the insurance company
  • Accepting kickbacks

 

To read the entire white paper click on the following link:  a white paper released by Jvion LLC,