What Hospitals Can Do to Prevent Health Insurance Fraud
While most health i...
Health insurance scams are on the rise, and the government and health care organizations are renewing their focus on stopping them.
While most health insurance providers are honest, there are some that sell fake policies and medical discount cards to their customers.
Advances in technology, better availability of information and greater awareness have helped the government, medical facilities, physicians and consumers combat fraud more effectively these days, but there is still a lot more to be done.
Here is a look at some common health insurance scams and measures that hospitals and other medical outlets can take to prevent them.
Fake Health Insurance Policies
Health insurance scammers often target individuals, small businesses and associations, and they try to trick them into buying their fake policies by promising low premiums and guaranteed approval without medical exams.
Many of them operate through sophisticated syndicates that have strong marketing and money-laundering capabilities, and they may even be linked to organized crime.
Usually, people who have purchased fake health insurance do not know that their policies are fake until they need to file claims.
Fake Obamacare Policies
While the implementation of Obamacare promises better health coverage for Americans, it also opened a new way for scammers to prey on health insurance buyers.
According to an article entitled "Health Insurance Scams Using Health Care Bill," health insurance scam artists began targeting seniors, low-income people and others who need health insurance desperately as soon as the new health care bill was passed.
While some of them offer fake Obamacare policies, others try to commit identity theft by telling their targets that they need their social security and bank account numbers to help them get a national health card.
Phony Medical Discount Cards
Phony medical discount cards are usually presented as a way to get discounts for various medical services or an alternative to health insurance.
These cards are often sold to low-income individuals and families. They come with lists of phony health care providers, fake discounts and high hidden fees, but they do not provide actual benefits.
Some of the sellers of phony medical discount cards also try to get people to disclose their personal information in an attempt to steal their identities.
Reducing Health Insurance Scams
There are a number of things that hospitals can do to prevent health insurance scams.
First of all, they can try to raise awareness of these scams and provide advice on how to avoid them. This can be done by sharing information about health insurance scams on their websites or newsletters, or during consultations.
Additionally, hospitals can use fraud detection software to combat health insurance fraud.
The Fraud and Abuse Management System developed by IBM is an example of software that can help them reduce financial losses that result from health insurance scams.
It detects fraud by analyzing claims data and identifying insurance providers that deviate from the norms of their peer groups. Some hospitals have set up special investigation units to prevent health insurance fraud.
Health insurance fraud can have serious consequences for patients, medical organizations, insurance providers and the government.
It is a costly crime that should not be overlooked.
About the author: John McMalcolm is a freelance writer who writes on a wide range of subjects, from social media marketing to cloud computing.
The future of pharma: personalised healthcare
Ever since the very first healthcare systems were created, the earliest documented being in ancient Egypt, medical professionals have had a reactionary approach to finding cures for ailments. That is to say that a solution is sought after someone has become sick, using whatever methods were thought to work at the time. Thousands of years later, with advances in genomics and molecular modelling, emphasis is starting to shift towards preventative, personalised healthcare rather than "sick care".
This move is led by data analytics as well as genetic sequencing to inform decision-making, which can ultimately lead to more individualised care. "Identifying the right data will support personalised health outcomes", explains Chris Easton, who is Takeda’s Senior Director and Global Commercial Lead, specialising in personalised health and innovation and applying this to rare blood disorders. "It's about how we can empower patients, interpret data and then apply it."
"The historic pharma model, in a very simplified form, is: a patient has symptoms, gets diagnosed, and gets given drugs for symptoms", Easton says. "Now, with holistic patient care in mind, it's much more about the additional components to care that would make a difference. Yes, drug therapy is one of them, but likewise, it's okay to talk about mental health, as the impact of chronic diseases means often there is a mental health challenge. So what can we do to build a mental health and physical health support package, both of which have data associated with them, that we can use together?"
By way of example, Easton cites the approach taken by elite athletes and astronauts. "Their model is to keep as healthy as possible. If someone on a space mission gets a cold, they're off the mission - it's not affordable to send someone to space that might have a health issue. If you look at footballers and runners, their coaches maintain them at the highest level, and they're using technology and wearables to help monitor their health so that they can make adjustments to stay at peak level for as long as possible."
The aim is to provide a complete, holistic package of care, which Easton acknowledges will pose some challenges to the pharmaceutical sector. "Our model is not necessarily that of a total care package. It's drug therapy or device and technology support therapy. So some things will need to evolve, and that's part of what my role is about."
One way of effecting this change is by collaborating with other organisations, not necessarily limited to healthcare and life sciences. "I'm a big advocate of partnerships and joint ventures. For the pharma sector, these are traditionally through universities and research houses, but I think we need to be willing to look outside the box and look for scalable and transferable technology that is used in everyday life."
"An example is the smartphone you probably have sitting on your desk or the smartwatch you're wearing. These are gathering data all the time. There are probably hundreds of data points that we could use, just from our everyday technology", Easton adds.
While apps like Apple Health, Google Health, and devices like Fitbit collect data, they could be linked to WhatsApp, WeChat or Telegraph to connect to members of a user's care team if a health issue arises. "It's using technology that is already embedded in our lives, that would enable us to share information and photographs. For example, if your knee is swelling and you want to ask a doctor for their opinion, you can send an image, then share the log from your treatment, and it becomes a way of integrating and sharing information."
Shifting towards preventative medicine is one of Takeda's strategic goals for the next few years. An example of how this could work is how people affected by Von Willebrand disease could be supported. This lifelong bleeding disorder prevents blood from clotting and particularly affects girls and women, causing menstrual bleeding to be excessively long and heavy, which has a big impact on their quality of life.
"It's a hereditary disorder, so many women in a family can be affected, but it's hard to diagnose", Easton explains. However, using existing technology that tracks the menstrual cycle via a smartphone perhaps an alert can be issued to let the user know when it's time to start taking replacement therapy for Von Willebrand.
"This means that by the time a period begins, Von Willebrand levels are normalised, and menstrual flow goes down to normal levels. That's actually a massive outcome for someone who has been living with two-week-long periods that bleed through clothing every month. Suddenly for just four or five days, they can use regular tampons and pads. That's a huge improvement to life."
The field of rare blood disorders typically hasn't seen the same amount of attention focused on it - at least in terms of tech innovation - as other chronic illnesses like diabetes. "Rare blood disorders are difficult to show returns on because you've got small patient numbers and often high costs. But if we think about the total patient journey, we could use technology to triage vast numbers of patients and data into more specific diagnosis boxes, so that what is then presented to physicians are smaller groups, of the more likely issues."
Data analysis could, for instance, show that the combination of headaches, nausea and lethargy equates to a specific type of bleeding disorder. "You can start to put these things in categories", Easton says. "And then you're able to do differential diagnosis. But ultimately, what you're trying to do is get a faster, more accurate diagnosis, leading to a specific therapy."
This would be more efficient than administering plasma-based treatments, for example. "A lot of bleeding disorders are caused by a deficiency of something", Easton explains. "There is a lot of combination therapy in blood disorders when you give people plasma-based products because plasma is like the golden chalice of medicine. It has a bit of everything you need. In some cases, when you don't know what the disorder is, this can help patients, but it's not the most precise way of doing it."
"That's one of the ways having very clear diagnostic support linked to advanced direct therapy can help, only treating what you need to. From a payer's perspective, it's very targeted, and there's no wasting money and resources on patients being hospitalised for things that are not necessary."
"If you go back 15-20 years, market access to the pharmaceutical industry was the emerging trend", Easton adds. "We saw all these diagrams of physician decision-making coming down and payer decision-making going up. Now we have another divergence of change, which is the application of technology to support personalised care. This is one of the transformative pieces of pharma right now, and there are a lot of good companies, big and small, being very intelligent about how they're approaching it and investing in those spaces. There's definitely a community building."