The latest annual estimates show improper payments to be around $72 billion within Medicaid and Medicare alone, despite the industry's best efforts to apply utilization management, claim editing, and other initiatives. Whether in government or commercial health insurance, the majority of this loss does not come from schemes and scams. Rather, the primary culprits are mundane billing waste and abuse-issues that by their very nature can easily hide in plain sight.
Our infographic explores how common healthcare billing practices can bypass an aging claim editing system or one that relies solely upon auto-adjudication, tallying up millions in potential fraud, waste, and abuse (FWA) payments. A recent look at one year of claims data across our clients showed that:
Unbundling represents the greatest share of coding errors, with over $96.2 million in identified prevented payments
Inconsistent billing practices have been identified 45,000 times, with avoided payments in excess of $4.2 million
Duplicate claims have represented 12 percent of billing errors and totaled over $21 million in in avoided payments