Audit Services and Investigations
Introduction: AvMed is committed to protecting member interests and corporate assets by detecting, investigating and preventing wrongful acts committed against the corporation. Pursuant to State and Federal Law, AvMed has established a rational, integrated, control-oriented anti-fraud program. AvMed consolidated its fraud and abuse/special investigative/revenue integrity functions with the establishment of the Audit Services and Investigations Department. Click here to view AvMed's Anti-Fraud Plan. Detection: Combating fraud and abuse begins with knowledge and awareness. It is impossible to prevent fraud and abuse without understanding what fraud is and how it is perpetrated on the health care industry. Health care fraud includes provider, member, eligibility, laboratories, pharmacies, billing agencies, medical suppliers, etc. Definitions: Claim Error: An unintentional deviation from accuracy that affects claim adjudication. Examples include, but are not limited to, unintentional billing errors, incorrect procedure codes, and dates of service errors, incorrect member name, and claim form mistakes. Abuse: Practices by providers, physicians, and suppliers and equipment, while not usually considered fraudulent, are nevertheless inconsistent with accepted medical, business, and fiscal practices. Examples include, but are not limited to, fragmented bills, unbundled charges, and treatment inconsistent with diagnosis. Fraud: The intentional deception or misrepresentation that an individual or entity knows to be false or does not believe to be true and makes, knowing the deception could result in some unauthorized benefit to himself/herself or some other person. Examples include, but are not limited to, intentionally billing for services that were not rendered, misrepresentation of charges for the services provided, misrepresentation of the identity of the provider or recipient of services, intentional misrepresentation of the condition treated or diagnosis made. Red flag examples to look for include, but are not limited to, early pressure for payment, threats on filing complaints with agencies or company, medical treatment appears unrelated, alteration of dates, charges, diagnosis, up coding for a more costly service or procedure than actually performed, provision of medically unnecessary services, tests, procedures, duplicate claims, inappropriate use of modifiers to inflate reimbursement, waiving of co-pays and deductibles, falsifying claims. Referrals and Reporting: Employees are encouraged to report suspected incidents of fraud or abuse to their supervisor, compliance, or Audit Services and Investigations Department. “Tips” are accepted directly from any employee, anonymously, if preferred. The FAU utilizes insurance fraud detection technology, utilizes fraud and suspicious claims referral services, and utilizes ongoing computer-based analysis of provider or member behavior for patterns of over/under utilization, exorbitant billing, and unusual billing practices. AvMed has system flags or edits to segregate claims with certain predetermined characteristics. A formal compliance program has been enhanced to include internal audit, claims, compliance, and the Audit Services and Investigations Department. Education of staff, providers, and members is a key element of the anti-fraud program. Referrals to the Audit Services and Investigations Department include tips from members, providers, general public, and employees. Referrals are also received from media reports, National Health Care Anti-Fraud Association, studies conducted by external vendors, law enforcement agencies, and the Department of Insurance. Where do you forward tips on fraud and abuse?
Prevention: AvMed has initiated a Fraud Awareness Campaign to encourage and assist employees and customers to identify, detect, and report fraud and abuse. All employees will attend the required education and training initially and every two years thereafter. All new employees will be educated as part of the orientation program. |
| Last modified November 30, 2006 |
