Healthcare Fraud, Waste, and Abuse
While unnecessary procedures and the submission of claims for services that were not performed may be the most common types of fraudulent activity in the healthcare industry, the most chronic areas for abuse are in the ambulatory services, durable medical equipment, and home health services. These large markets, which are made up of thousands of small businesses and high daily transaction volumes, make oversight difficult – and claims difficult to validate.
Dun & Bradstreet can help agencies curb abuse and keep costs down by standardizing provider registration processes, verifying provider information with third-party data, and tracking the relationships between businesses and individuals.
Verification of Regulated Entities and Goods
Responsible for protecting the public health by assuring the safety of health-impacting products, agencies must regulate ever-expanding lists of products, materials, manufacturers, and global supply chains. The challenge is amplified by the need to draw mission-critical information from a multitude of disparate, multi-owner databases.
By leveraging Dun & Bradstreet's best practices, such as the implementation of a unique entity identifier, government agencies can streamline facility verifications, facilitate interagency information sharing, and more effectively improve public health outcomes.
Standardized Registration Process
The creation of a standardized registration process for healthcare providers represents a powerful opportunity to prevent fraud. For example, the U.S. Centers for Medicare and Medicaid Services has implemented the Automated Provider Screening (APS) system in an effort to identify high-risk providers; yet, each jurisdiction maintains its own system for onboarding. Inconsistent and insufficient data entry requirements have allowed large numbers of high-risk providers to successfully register, including providers who were previously excluded in other jurisdictions for fraudulent billing.
Dun & Bradstreet can help with provider verification across multiple jurisdictions, continuous monitoring of good standing, and consistent input requirements among government healthcare systems to support modeling, fraud scoring, and risk analysis.
Provider Information Verified with Third Party Data
No matter how rigorous, registration processes cannot provide all the information required to flag high-risk providers. The lack of third-party data curtails payer abilities to verify and obtain insight into provider-reported information – relying solely on self-reported information exposes agencies to outdated data and an increased fraud risk.
To obtain a complete view of potentially fraudulent behavior, payers should add business information provided by objective third parties to fill in the gaps inherent in the usual data sets that payers aggregate. Dun & Bradstreet's Healthcare Provider Risk Index is a proprietary risk-scoring system that evaluates and ranks providers' relative potential to demonstrate characteristics consistent with known instances of fraud, waste, and abuse.
Other Government Solutions
Total healthcare spending in America is $2.7 trillion or 17% of GDP. Fraud (and the rules and inspections to combat it) adds as much as $98 billion or roughly 10% to Medicaid and Medicare spending – and up to $272 billion across the entire health system.