Healthcare is one of the most important factors in how individuals perceive their quality of life.i But quality health care comes at a price and precious healthcare funding is being lost to fraud, waste and abuse (FWA). In fact, an estimated $455 billion in global healthcare spending is lost every year – ultimately leading to lower quality care and higher premiums and taxes.ii
Everyone plays a role in combatting FWA, but healthcare payers are on the front lines. Recently, three major trends emerged that present an opportunity for healthcare payers to play a major role in combating FWA. Let’s take a look at the way these trends are changing the healthcare landscape.
1. Plenty of healthcare data, not enough insights
Healthcare executives would like to leverage big data, but only a few are able to gain EDI data insights and visibility needed to garner the results they need to address FWA in their organizations. Many healthcare executives have access to an unprecedented amount of data, such as the information stored in electronic medical records, smart devices and online portals. In a recent Managed Healthcare survey, 51% of respondents said their organizations are using big data, but when asked, “how well would you say your organization is using big data to improve healthcare quality and reduce costs?” only 11% of respondents said, “very well.”iii As a result, healthcare providers have a limited capacity to recognize and reduce wasteful spending. Organizations will not be able to address improper spending due to FWA until they have the visibility and insights needed to identify where it is happening.
2. Decentralized communication between payers and providers
Failures of care coordination between providers can harm patients and add to the expense of healthcare. Healthcare systems today are expanding. The problem is that as these healthcare systems continue to grow, so will the need for providers and payers to coordinate care. For example, a physician could interact with as many as 229 other physicians across various practices each year.iv With these critical interactions occurring across locations and practices, important information is obscured. For healthcare payers it’s essential to have visibility into diagnoses and care decisions to prevent FWA. As care coordination becomes more technical, added complications in billing arise, leading to an increase in unintentional, but costly, mistakes that contribute to FWA. Healthcare systems will continue to grow and become more complex, and without greater collaboration FWA will continue to grow as well.
3. Growing government requirements
Healthcare regulations are increasing around the globe. From increased coding standards to the various reauthorization acts, it has been said that “healthcare is turning into an industry focused on compliance and regulation rather than patient care.”v Although these standards and acts are well intentioned, this is putting a strain on healthcare organizations in the form of wasted time and money. For example, 41% of payers see their biggest challenge as “complying with new government requirements and mandates.”vi One example of these increasing regulations is ICD-10, which contains a new level of classification for coding diseases and symptoms. While these standards enable precise care documentation, they also introduce a new layer of complexity and can cause confusion. With the right level of visibility and centralized communications, healthcare payers will be better able to manage these increasing regulations. Today, new tools enable healthcare payers to predict and prevent FWA.
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