skip navigation

PUBLICATIONS

Register for Latest Research

Stay Informed
Register with NCJRS to receive NCJRS's biweekly e-newsletter JUSTINFO and additional periodic emails from NCJRS and the NCJRS federal sponsors that highlight the latest research published or sponsored by the Office of Justice Programs.

NCJRS Abstract

The document referenced below is part of the NCJRS Virtual Library collection. To conduct further searches of the collection, visit the Virtual Library. See the Obtain Documents page for direction on how to access resources online, via mail, through interlibrary loans, or in a local library.

 

NCJ Number: 68147 Find in a Library
Title: 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)
Author(s): W C WHITE
Date Published: 1979
Page Count: 5
Sponsoring Agency: Superintendent of Documents, GPO
Washington, DC 20402
Sale Source: Superintendent of Documents, GPO
Washington, DC 20402
United States of America
Language: English
Country: United States of America
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)
Index Term(s): Crime prevention measures; Medicaid/Medicare fraud
Note: NCJ 68147 AVAILABLE ON MICROFICHE FROM NCJRS UNDER NCJ-68143.
To cite this abstract, use the following link:
http://www.ncjrs.gov/App/publications/abstract.aspx?ID=68147

*A link to the full-text document is provided whenever possible. For documents not available online, a link to the publisher's website is provided. Tell us how you use the NCJRS Library and Abstracts Database - send us your feedback.