Fraud and Abuse in Health Insurance Industry
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Fraud and Abuse

Verscend understands how important it is for health plans to do periodic audits to identify any type of fraudulent billing practices.

According to the National Health Care Anti-Fraud Association, estimates are that 3% to 10% of health care spending is lost to health care fraud. This means that the price tag associated with health care fraud can range anywhere from $68 billion to $226 billion each year.

Verscend’s Fraud and Abuse group consists of an experienced team of coders who audit retrieved medical records to ensure that the codes on submitted claims follow plan guidelines. Coders check for instances of up-coding, charging for services never rendered, or manipulation of information within the medical record or claim which results in incorrect reimbursement.

Effective auditing requires an understanding of coding principles. To satisfy health plan requirements, the codes billed to a health plan must be supported in the medical chart. When performing a chart audit, Verscend coders do the following:

Review all CPT/HCPCS Codes Submitted

Coders determine if the documentation in the chart supports these codes.

Review all Modifiers

Coders determine if the documentation supports the use of specified modifiers.

Review all ICD-9 CM Codes

Coders determine if the documentation supports these codes.

Review the Dates of Service Billed

Coders validate that these dates of service are included in the medical record and were performed.

Review Documentation

Coders ensure that all notes are legible, dated, and signed.

Performing regular coding audits allows health payers to recoup any overpayments that were made due to incorrect billing and also helps plans identify consistent billing errors that may indicate fraud and abuse in billing practices. Identifying these issues early on can save the health plan millions of dollars in overpayments.

Provider Education

As an invaluable resource to both health plans and the providers included in any coding audit, provider education materials are a tool to help providers identify areas for improvement in their record documentation and also provide general coding guidelines. Verscend has standard provider education materials but can also develop additional customized materials.

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