The cost of healthcare has been steadily increasing for years, especially in the past decade as drivers such as advancement in technology and federal regulation have expanded so rapidly. While some may be inclined to pay these higher bills without scrutiny, an increasing population of auditors is starting to examine charges more carefully- and the findings are astonishing.
One article suggests that in the work comp industry alone, the failure to properly audit medical bills has cost more than $2 billion annually in unjustifiable claims. Although insurance carriers staff nurses and physicians to review the necessity of treatments, many needless services still slip through the radar. In a recent hospital audit conducted by a group health plan, it was revealed that one patient’s 19-day stay was billed incorrectly by more than $20,000. So, how is this happening in such a regulated industry?
In addition to intentional schemes such as unbundling codes or tacking non-administered services onto a bill, many excess payments are remitted due to a lack of software integration. Bill review systems have typically operated separately from UR and UM databases. Despite the fact that a service may be denied, the original requesting paperwork can easily be sent to a payment site and processed through unnoticed.
Also, there is a fair chance that the amounts assigned to each service could be slightly higher than the usual and customary charge; if a full bill review could be conducted on each code, the actual amount could be thousands of dollars less.
Financial recovery teams are beginning to conduct much deeper investigations and bringing on third parties to assist with questions related to: medical necessity; generic vs. over-the-counter alternatives; usual and customary charges; coding appropriateness and fraudulent patterns. AMR’s panel has assisted dozens of clients in recouping hundreds of thousands in unnecessary charges.
Our focus is to ensure that services paid are actually medically necessary so we can improve the quality of healthcare administered- and therefore improve cost savings as well. As the price of healthcare continues to rise, the over and unnecessary payments, more than ever, need to be cut.
Dr. Alpern has been involved in scientific and medical research throughout her career and has authored multiple book chapters and articles in peer-reviewed journals. She has been an invited speaker and presenter at a variety of national and international scientific and medical conferences. In addition to completing a residency in Diagnostic Radiology and becoming a board certified Radiologist, Dr. Alpern has also completed fellowships in Medical Informatics, Breast Imaging, as well as Abdominal Imaging. After finishing her training at UCLA Department of Radiology, Dr. Alpern has worked in a very busy clinical practice in Los Angeles. She was a co-investigator in a variety of clinical trials and was involved in researching clinical applications of the newest imaging equipment with Siemens.
By DR. LOUSINE ALPERN