The DOC: Billions Lost as Healthcare Fraud and Abuse Escalate

AUDIT SPOTLIGHT

Billions Lost as Healthcare Fraud and Abuse Escalate

By Cynthia Swanson, RN, CPC, CEMC, CHC, CMPA, Vice President of Audit Services

The U.S. Department of Justice estimates that healthcare fraud, waste and abuse cost the U.S. as much as $100 billion each year. Because annual healthcare expenditures now exceed $1 trillion, these losses are likely to keep growing. The National Health Care Anti-Fraud Association estimates that fraud alone costs the U.S. $68 billion.

This drains vital resources, undermines trust, inflates costs, and harms patients and providers alike. The ongoing escalation of fraud, waste and abuse has prompted the government to step up its enforcement.

Health Insurance Is a Mess; How’d We Get Here? – Part 2

Can the problems with health insurance actually be fixed?

In Part 2 of this ClaimTalk conversation, CEO Ben Krambeck, Vice President of Provider Relations Brad Hansen and Vice President of Audit Services Cynthia Swanson continue unpacking how we got here — and what it will take to change course. Building on Part 1, they explore with host Danielle Young how well-intentioned innovation, shifting demographics and policy decisions have combined to create a system that’s increasingly expensive, complex and unsustainable for employer health plans.

More importantly, they move beyond diagnosis to discuss what a path forward could look like. They address the unexpected negative impact of consumer transparency rules, the role of legislation and skyrocketing pharmacy costs.

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Panama City, Florida

Hospital Bill $513,715.26

A 21-day hospital stay for the treatment of a heart attack with a related

cardiac catheterization laboratory procedure.

	Plan	Member
Traditional Network Plan	$180,142.04 Median Commercially Contracted Price	$36,028.41 Patient Responsibility (20% Coinsurance)
DirectAccess+	$96,911.51 ClaimDOC Allowable	$19,382.30 Patient Responsibility (20% Coinsurance)
Savings	$83,230.53	$16,646.11

Read more audit examples

To establish savings information, ClaimDOC analyzes commercial contract pricing from data disclosed by hospitals and health plans. The audit team performs line-by-line claim audits to help clients and members maximize their savings.

Service Shoutout

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AUDIT SPOTLIGHT﻿

Billions Lost as Healthcare Fraud and Abuse Escalate

Health Insurance Is a Mess; How’d We Get Here? – Part 2

AUDIT SPOTLIGHT