Is your ASC at risk? — ACL's Dan Zitting & Phil Lim provide insights on healthcare fraud

Fraud is a growing threat to healthcare providers around the nation and there are several steps to take to make sure you're protected.  

"Providers can do simple things to build awareness of what fraud looks like and figure out other places to look," says Dan Zitting, vice president of product management and design of ACL. ACL is a software company that provides auditing and GRC solutions to large and small health firms around the world. Mr. Zitting is seasoned in detecting healthcare fraud and has worked for the last decade using data to detect fraud in organizations.

Although providers and payers are both at risk for fraud, payers particularly need to be on high alert and ensure they are protected on all fronts.

"It is pretty incredible how much fraud you can identify through false claims or through provider fraud such as providers overstating services or submitting false services," says Mr. Zitting.

Providers have other areas of concerns. They have to closely monitor clinic operations to prevent employees from committing intentional and unintentional fraud. "Providers can identify the trends in the use of medical devices and compare inventory against the actual services provided," says Phil Lim, content solutions manager of ACL.

This may be a tedious task, but prudent when assessing fraud in a clinic. Healthcare firms need to be aware of and fully understand the Fraud Triangle. The Fraud Triangle was developed by criminologist Donald Cressey, PhD. Dr. Cressey's Fraud Triangle consists of three parts — pressure, opportunity and rationalization. If an employee is facing pressure and sees an opportunity, the employee can rationalize the fraud is acceptable.

"When the triangle comes together, there is opportunity for fraud," says Mr. Zitting. "Common areas where the fraud manifests for providers are inventory, theft in areas like cash reception, understating what was billed and inappropriate expenses."

Both small and large providers understand the rising threat fraud presents, and are taking measures to ensure they are not at high-risk. Providers often will utilize either an internal or an external audit group that will conduct various types of risk assessment by looking at coding audits, purchasing audits, payroll audits and drug inventories.

"We never find significant size providers without audit professionals because there is so much risk of fraud," says Mr. Lim. "Auditing professionals are critical to make sure organizations are protected."

Providers often practice medicine to serve the greater good, and often the lines can get blurry about how to best serve patients. Sometimes when providers are trying to help patients, they are breaking the law and committing fraud.

"It can get pretty easy for individual physicians or others in the organization to say let's waive a patient's copay and then submit other claims to cover the copay," says Mr. Zitting. "It is the combination of pressure on the patient and their ability to pay as well as justification it is good for the patient. At the end of the day, it is still fraud."

Healthcare fraud will only continue, and healthcare organizations need to be protected from all angles. They should be aware of the latest technologies even if a provider does not have a large amount of resources to allocate toward detecting fraud.

"Budgets are always the challenge here," says Mr. Zitting. "Even for the smallest providers, there is quite a lot of data available as more and more of the process of providing healthcare becomes digital."

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