Tom's Take | September 30th, 2019

Is the industry seeing any resolution with inaccurate and fraudulent health claim billing?

Tom’s Take: Unfortunately, the health care industry has long been plagued by widespread issues of mis-billing. Think about it for a minute. How often do we see reports of extreme overcharges in the news that have us gasping at the thought of being billed hundreds of dollars for something as simple as a single dose of ibuprofen or leftover pack of gauze pads?

But it’s because of stories like these and the amount of coverage they’ve received in the last several years that some of the problem areas with billing are actually being dealt with.

Patients, employers and health plan administrators have all become more aware of the need to scrutinize claims and they’re realizing the financial payoff that can come from being so diligent. Third party administrators (TPAs) are using more advanced processes than ever before to analyze client claims, and employers are on board with allocating the appropriate resources to review these claims so thoroughly.

Another positive I see is that TPAs and claim analyzers have become more knowledgeable about the variety of things to watch for. It’s not always a simple coding error on a claim, but oftentimes a duplicate charge, a wrong service billed or a procedure that’s been unnecessarily upcoded or unbundled.

And on top of all that, people are getting more vocal. If something seems overpriced or fraudulent in nature, they’re going to the source and asking questions. There’s more negotiating on behalf of plan members happening when prices seem unreasonably high, and peer independent reviews are coming into play when another medical opinion is needed.

At Cypress, we continue to rely on our experienced team of analysts to do a comprehensive check of employer-client health claims. Taking the approach of diligently poring over charges in the day-to-day claims adjudication process has been quite successful in uncovering inaccuracies, and it continues to lead to significant savings opportunities.

There still may be a lot of mis-billing happening that’s beyond our control, but it’s refreshing to see so much progress being made through more in-depth claims analysis and follow-ups. I’d like to believe that with this kind of focus, the number of mis-billed health claims will become fewer and less frequent over time!


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