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How to control misuse of health insurance by high spending providers? or what are the cost control measures that an insurance company can implement over the providers?

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Question ajoutée par junaid yusaf , Senior Claims Auditor/ Accessor- Medical , Maxcare Middle East
Date de publication: 2016/02/13
Rehan Qureshi
par Rehan Qureshi , Financial Consultant , Self Employeed

 Vinod Jetley has given a good answer

Vinod Jetley
par Vinod Jetley , Assistant General Manager , State Bank of India

Efforts to combat fraud were consolidated and strengthened under Public Law-, the Health Insurance Portability and Accountability Act of (HIPAA). The Act established a comprehensive program to combat fraud committed against all health plans, both public and private. The legislation required the establishment of a national Health Care Fraud and Abuse Control Program (HCFAC), under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS) acting through the Department's Inspector General (HHS/OIG). The HCFAC program is designed to coordinate Federal, State and local law enforcement activities with respect to health care fraud and abuse. The Act requires HHS and Department of Justice (DOJ) detail in an Annual Report the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such deposits

Rajendra Sharma Raj
par Rajendra Sharma Raj , Consultant , Confidential

Fraud and Abuse is an area of concern for almost all the insurance companies in USA. If the model is same in the GCC then below are the possible solutions:

Peer utilization or claim report: If an insurance company analyze physician groups and peers and publish a report of their services provided for a problem. This can be a best way to identify future cost measures and policy making

Analytics: Well this is the main part which will find the claim patterns of a particular doctor

Many more depends on the payment model.

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