Question

List three examples of insurance fraud and three examples of insurance abuse. Using your textbook

Insurance Fraud and an id and Abuse Insurance fraud and abuse may be involved in more tha of submitted medical claims Competency Integrity Information both intentional billing irregular slich irregulari the practice on for or having sonnel involved alert for both should begin by identifying risk areas based on errors in the past history of billing and insurance more than 109 claims processing. Practice internal audits to mon- ency Integrity accordin dical claims or compliance with written protocols. Partici- ou Institute. These estimates include 8 to the Insurance pate in seminars and in-service programs to keep ional as well as accidental coding and Current with coding and billing practices. Be sure to use only the current year's coding manuals to irregularities and, if deter tected and proved. ensure accuracy. Code only what is documented in irregularities can result in leg ce or clinic and personnel responsible legal action against the medical record, and ask for clarification when needed need iving knowledge of the irregularities. Per An auditor should check claim forms, whether volved in coding and billing should be submitted electronically or by hard copy, to see both accidental and intentional coding that they are completed correctly. Include all per billing irregularities and brin oing them to the tinent dates and diagnostic and procedural cod- of responsible managers. If no correc- ing information necessary for insurance payers vion is taken, all personnel involved, includ to generate reimbursement. Auditors look spe sponsible to report the citically for any indicators of insurance fraud and ities to the insurance carrier. Examples of abuse. insurance activities include but are not and billi that th attention of responsible and bring that coding tive action is taken, all perslanagers. If to the ing managers, are le ing in dates an lommand diar correcthard cor ularities to the gally rehelinino fraudulent insu msurance surancesible ed, inc limited to: ment . Coding to a higher level of servi revenue (upcoding) of service to increase PROFESSIONAL CAREERS IN INSURANCE Misrepresenting the diagnosis to justify pay To be successful in the health insurance specialist field, training and entry-level . Billing for services, equipment, or procedures requirements are essential. An oppor- Professional tunity for employment in these special- that were never provided ties is greater for those with a college degree that . Unbundling service procedure codes includes course-work in medical terminology, . Charging uninsured patients less than insured anatomy and physiology, pharmacology, insur- patients ance and coding procedures, and communication skills. • Receiving rebates or any type of compensation Personal attributes that enhance employment for referrals (kickbacks) possibilities as health insurance specialists include, but are not limited to, the following descrip- Insurance abuse involves activities that are incon- tions: self-motivated, works well independently, sistent with accepted business practices. Some detail oriented, a critical thinker, ethical, main- examples of abuse include but are not limited to: tains confidentiality, cooperative, reliable, and adaptable. • Charging for services that are not medically The following Internet links will help you necessary explore a variety of health insurance specialist • Overcharging for services, equipment, or pro career opportunities. cedures • American Academy of Professional Coders • Improper billing practices (AAPC) at http://www.aapc.com • Violating participating provider agreements American Health Information Management with insurance companies Association (AHIMA) at http://www.ahima .org Heavy penalties, including a $10,000 fine per • American Medical Billing Association claim form plus three times the fraudulent claim (AMBA) at http://www.ambanet.net amount, may be sanctioned on individuals who knowingly and willfully misrepresent informa- lion submitted on insurance claim forms to gain greater payments or benefits. • Alliance of Claims Assistance Professionals (ACAP) at http://www.claims.org • National Electronic Billers Alliance (NEBA) at http://www.nebazone.com To protect yourself and the medical practice n committing insurance fraud and abuse, you

Answer 1

Health insurance in which the medical,surgical and other emergency hospital care expenses are paid by insurance companies. The basic insurance plans are Health maintenance organization,Exclusive provide organization, Preferred provider organization.

Insurance fraud is an act of creating fake information in order to get higher payment for the treatment.Three examples for insurance fraud are

1) Coding to a higher level service to increase revenue.

2) Misrepresenting the diagnosis to justify the payment.

3) Billing for services,equipments or procedures that are not provided.

Insurance abuse is provider practice that are not consistent with medical practices and as per medicare and medicaid program. Three examples of insurance abuse are;

1) Charging for services that are not medically necessary.

2) Improper billing services.

3) Violating participating provider agreements with insurance companies.