Most Costly Sources of Healthcare Fraud

According to a study of commercial insurance claims data conducted by Truven Health Analytics, six common claims scenarios accounted for nearly a million dollars in overpayments annually for each of the organizations in the study. Together, these six factors cost each organization in the study $4.93 per member per year (a figure that includes the employee and his/her dependents) in unnecessary payments. Following are the six most costly drivers of healthcare fraud, waste, and abuse from the study:
Schedule II Drugs without Physician Care ($84.3 million): Over 20 percent of patients that received Drug Enforcement Administration (DEA) Schedule II drugs - such as Vicodin(R), Oxycodone, Cocaine, Morphine, and Ritalin - had no associated medical visit 90 days before the receipt of prescription.
Refills on Schedule II Drugs ($5.2 million): Nearly one percent of patients receiving Schedule II prescriptions received refills despite the fact that refills on Schedule II drugs are prohibited by federal law.
Multiple New Patient Visits (18.5 million): American Medical Association guidelines stipulate that a physician can bill patients for only one "new patient" visit every three years. But the data revealed that 1.4 percent of visits and 1.3 percent of the cost associated with new patient visits violated that guideline.
Improper Distribution of Diabetic Supplies ($8 million): Overall, 7.4 percent of patients and 5.1 percent of the costs for diabetic supplies were for patients with no diabetic diagnosis. This represented $3,894,466 of questionable spending in 2010 and has grown to $8 million in just two years.
Unbundled Psychotherapy/Drug Management Services ($5.3 million): In instances where both psychotherapy and drug management services are provided together, the two should be billed using a code that includes both services. The research shows that 1.8 percent of patients receiving psychotherapy services also had bills on the same day from the same provider for pharmaceutical management services.
Wasteful Medical Transportation ($1.3 million): Over five percent of patients and 4.6 percent of medical transport costs had no associated medical visit.
Source: Truven Health Analytics