Preventing Fraud and Abuse in Managed Care

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I. Introduction
II. Statistical data about healthcare costs and fraudulent claims.
III. The challenge of healthcare fraud.
1. Most common fraud types.
a. Fraud done by physicians
b. Fraud done by billing
c. Fraud done by transportation
2. Who is at risk due to fraud
IV. How to prevent fraud and abuse in Managed Care
1. Compliance activities required of managed care plans
a. Written policies, procedures, and standards of conduct that articulate the organization’s commitment to comply with all applicable Federal and State standards.
b. Effective training and education for the compliance officer
c. Internal monitoring and auditing
2. Prevention of Fraud
3. Detection of Fraud
4. Investigating and Reporting Fraud

Works Cited
https://www.nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-fraud.aspx

The Medicaid Managed Care Plan’s Role in Preventing Detecting, and Reporting Fraud, Waste and Abuse.
https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Provider-Education-Toolkits/Downloads/managedcare-role-factsheet.pdf