When the way healthcare gets paid changes, fraud changes with it.
The shift from fee-for-service toward value-based care was designed to reward better outcomes rather than simply more services.
But changing financial incentives doesn’t eliminate fraud, waste and abuse.
It changes where organizations need to look for it.
→ Diagnosis accuracy.
→ Risk adjustment.
→ Patient attribution.
→ Quality measures.
→ Provider relationships.
→ Documentation.
→ Shared savings.
→ Coding patterns.
The financial relationships become more interconnected — and so can the opportunities for manipulation.
We wrote about this trend as value-based care adoption accelerated, and the issue has only become more important as Medicare Advantage, Medicaid and other government programs receive increasing program-integrity scrutiny. Our earlier analysis noted that identifying FWA in value-based models can require more sophisticated analytics because the risks are not always as straightforward as traditional fee-for-service schemes.
The takeaway?
New payment models require new investigative thinking.
Organizations need the ability to move beyond identifying questionable data and investigate the behavior and documentation behind it.
Because innovation in healthcare payment will inevitably be followed by innovation in healthcare fraud.
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SOURCE: CoventBridge Article: https://lnkd.in/e9viWQQ2
