Controlling Fraud, Waste, and Abuse in Healthcare
Learn about the definitions and current situation regarding Fraud, Waste, and Abuse (FWA) in healthcare, particularly in the UAE. Discover the main contributors to FWA, such as over-prescription and misconceptions about health insurance. Explore effective methods to control FWA using data analytics to detect trends, analyze findings, and prevent recurrence.
Uploaded on | 0 Views
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
You are allowed to download the files provided on this website for personal or commercial use, subject to the condition that they are used lawfully. All files are the property of their respective owners.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author.
E N D
Presentation Transcript
Controlling Fraud, Waste, and Abuse
Definitions and Current Situation
What is FWA? What is FWA? FWA can be defined by: Fraud benefits Waste comfort levels Abuse Fraud: Intentional deception to obtain illicit Waste: Excessive use of services based on Abuse: Unsubstantiated payment for services
FWA in the UAE FWA in the UAE FWA is estimated to represent between 5% and 10% of claims spending. It is lower than estimates in other countries (e.g. US) for the following reasons: Compulsory health insurance: less need for identity theft Widespread availability of direct billing to payers: fewer reimbursement claims by members Adoption of international standards and e-claims: enables streamlining of adjudication processes and meaningful analysis of claims data Introduction of DRG s: rewards quality as opposed to pay-for-service Strict monitoring of restricted medications: cf. MOI initiative
FWA in the UAE FWA in the UAE Waste constitutes the main contributor to FWA due to: Some medical providers incentivize doctors to over-prescribe Only recently do patient have access to readily available and reliable information to select a physician Comfort levels associated with various insurance products are not easily defined / communicated Pressure on providers to make-up for lost revenue due to demographic fluctuations and / or increased competition Many patients and doctors still have mistaken beliefs about health insurance
How to Control FWA How to Control FWA The answer is straight-forward: Data Analytics Data Analytics Using the powerful tools now available, payers can build an effective strategy to: Detect abnormal trends and notable variations from established benchmarks Analyze thoroughly the findings before jumping to conclusions Field Audit to document findings for a potential financial recovery Prevent the (re)occurrence of similar situations by reviewing existing methods and processes
Other Important Initiatives Other Important Initiatives Regulators and the health insurance industry need to cooperate to introduce new initiatives that can significantly further reduce FWA Encourage providers to stop prescription- related incentives to doctors Encourage the empowerment of Medical Committees at large providers to ensure quality standards and self-policing against dubious practices Electronic Health Records that eliminate repetitive tests at different providers Introduce e-Prescriptions for all outpatient prescriptions and enable direct and efficient interaction between doctors and payers Introduce guidelines for monetary recoveries resulting from field audits. This is particularly relevant for TPAs. Establish an arbitration chamber under the authority of regulators to decide on disputed claims
Conclusion Conclusion Technology and Analytics are the best immediately available tools to combat and control FWA.
