MODEL SYSTEMS- ABUSE DETECTION CONTROL (FROM SECRETARY'S NATIONAL CONFERENCE ON FRAUD, ABUSE, AND ERROR PROTECTING THE TAXPAYER'S DOLLAR, P 28-32, 1978 - SEE NCJ-68143)

• NCJ Number: 68147
• Author(s): W C WHITE
• Date Published: 1979
• Length: 5 pages
• Sale Source: Superintendent of Documents, GPO
• Language: English
• Country: United States of America
• Note: NCJ 68147 AVAILABLE ON MICROFICHE FROM NCJRS UNDER NCJ-68143.

Annotation

IMPROVED TECHNIQUES HAVE BEEN DEVELOPED BY CARRIER, CONTRACTOR, AND STATE CASE INVESTIGATORS FOR UTILIZATION CONTROL IN MEDICAID AND MEDICARE PROGRAMS.

Abstract

THE MOST COMMON FORM OF ABUSE IN EITHER PROGRAM IS OVERUTILIZATION OF SERVICES, A SUBJECT THAT IS SEEN DIFFERENTLY BY EACH DOCTOR ATTENDING CLIENTS. MEDICAID TYPES OF OVERUTILIZATION INCLUDE UNNECESSARY VISITS TO OR SERVICES BY DOCTORS, A VARIETY OF DIAGNOSES THAT VARY FROM VISIT TO VISIT ON A PATIENT, OR A DOCTOR WITH AN UNUSUAL NUMBER OF TEENAGE PATIENTS. MEDICARE DATA REVEAL MORE ABUSE IN THE HOSPITAL SETTING IN TERMS OF EXCESSIVE STAYS AND BILLING FOR CONCURRENT AND DAILY SPECIALTY CARE. HOWEVER, THERE IS A FINE LINE BETWEEN OVERUTILIZATION AND ABUSE AND DIFFERENTIATION OFTEN REQUIRES HUMAN JUDGMENT. YET COMPUTER STUDIES CAN COVER PRACTICE PATTERNS OVER BOTH SHORT TERMS AND LONG TERMS AND PERMIT THE SELECTION OF UNIQUE OR EXCEPTIONAL VARIATIONS IN SERVICE DELIVERY WITHIN AREAS OR PEER GROUPS. THE MEDICARE MODEL B CLAIMS PROCESSING SYSTEM USES SUCH PREPAYMENT SCREENS TO DETECT DUPLICATE BILLS RECOGNIZE CONSISTENT AND REPEATED CASES OF UNNECEASSARY CONCURRENT CARE BY VARIOUS SPECIALISTS. MODEL PREPAYMENT SCREENS PROVIDE GREAT FLEXIBILITY IN THE APPLICATION OF BOTH QUANTITATIVE AND TIME MEASURES OF SERVICE UTILIZATION; THE PROCEDURES LISTED IN THE PREPAYMENT SCREEN CAN BE CHANGED AND TIME PERIODS TO BE REVIEWED CAN BE ADAPTED TO CHANGING CLAIM CONDITIONS. ALSO USED IS A DEVICE CALLED PARE (PAYMENT REVIEW) WHICH REVIEWS PROVIDER PAYMENTS WITH EARNINGS ABOVE A PREDETERMINED AMOUNT. PARE INVOLVES A WHOLE SYSTEM OF INVESTIGATION OF CLAIMS, CHARTS, CLAIM HISTORIES, AND AN ADVISORY PANEL MADE UP OF PRIVATE PHYSICIANS. FINALLY, THE MEDICAID MANAGEMENT INFORMATION SYSTEM (MMIS) OPERATES WITH RECIPIENT, PROVIDER, CLAIMS PROCESSING, MANAGEMENT STATISTICAL, AND OVERUTILIZATION FILES. THUS ABUSE CAN BE DETECTED AND SCREENED EVEN IN CLAIMS PROCESSING OF GREAT MAGNITUDES, BY THE USE OF TESTED DATA MANAGEMENT AND STATISTICAL TECHNIQUES COUPLED WITH THE JUDGMENT AND ACCUMULATED EXPERIENCE OF CLAIMS PERSONNEL. (MHP)