As healthcare reform continues to shift the industry’s focus toward prevention and wellness, business owners are forced to adapt.
John LeBlanc of Manatt, Phelps & Phillips, who specializes in healthcare law, tells us that the shift is due to “the fact that there is so much more emphasis on rewarding value-based purchasing.”
On top of that, he adds, “we’ve also got the Affordable Care Act which is putting another set of incentives out there to reward quality and efficiency.”
The changes are front-loaded with upcoming new reimbursement models. “[For] so much of this industry, it’s more than just about fraud, waste, and abuse,” LeBlanc explains. “It’s about the structure and payment methodologies by which we pay for things.”
For example, in Medicare and Medicaid alone, LeBlanc notes that “there are approximately 9 out of 10 medical claims that have some element of fraud or improper payment.
In addition to the various regulations imposed on healthcare providers from both federal and state governments, insurance companies are combatting the issue.
These third-party payers, or insurers, have a lot of potential leverage – they can increase premiums and deductibles until providers start to feel the effects.
“If they ratchet those down too much,” LeBlanc says, “they’re going to be paying for everybody’s healthcare, and they won’t make any money.”
LeBlanc believes that insurance companies are doing their part in combating fraud, and he praised them for it. “There was a time when the insurance industry wasn’t interested in looking at these things,” LeBlanc says. “[They were] letting providers run wild with bad behavior, and [now] they’ve woken up.”
Still, LeBlanc says some healthcare providers have not “gotten the memo” on what insurance companies are looking for.
“There are certain things that an insurer is going to see over and over again where they know it’s indicative of fraud,” LeBlanc explains.
For example, “a diagnosis that is provided without the proper documentation, [or] a diagnostic procedure that’s just not covered by their insurance,” he says.
“Those are the kinds of things that they’re going to be stopping and investigating.”
One potential red flag for healthcare providers in LeBlanc’s book is when they start seeing more than one payer for the same patient.
“If you’re billing for a chiropractic visit and I also see that you’ve got some other kind of treatment,” LeBlanc says, “that’s something that’s going to catch my eye and say ‘maybe there is some other type of fraud going on.'”
LeBlanc notes that it could be anything from insurance fraud to billing for services the patient received but didn’t realize they were being charged for.
“If you bill me for something, I should have it,” LeBlanc says. “I shouldn’t have to go looking for it.”
LeBlanc adds that even if a facility is entirely up-front about all of its billing if their claims are drastically higher than the norm, it’s likely that an investigation could be initiated.
“When you’re looking at a healthcare provider,” LeBlanc says, “you want to see whether they have reasonable charges for services rendered.”
LeBlanc concluded by saying that the goal of a successful investigation is to “determine what you’re going to pay for an office visit or a surgical procedure, and that’s going to reduce the amount of fraud, waste, and abuse.”
As long as healthcare providers document their procedures correctly and treat patients with respect, LeBlanc says they have nothing to fear from insurance companies.
“The insurance companies are looking to pay what is reasonable,” LeBlanc says, “and they’re not looking to buy stuff they didn’t get.”