Problem 1: There is a natural tension between the desire to safeguard and protect medical information and health insurers' need to collect this information in order to properly underwrite health risks. Discuss the motivations for using medical information - histories, genetic information, utilization of services, etc. - from the perspective of a health care provider. What is the appropriate balance between safeguarding and sharing medical information with insurers?
Problem 2: Choose one of the top 10 historically used data searches and explain why you think fraud, abuse or waste in that type of service/procedure could be revealed in billing or other data.
Top 10 Areas Historically
- Top paid procedure (CPT/HCPCS II) codes - Providers identified as outliers
- Time bandits
- Recipient age not appropriate for code (tests/procedures on young children)
- Services after death
- Urine drug screening
- Personal care services
- National correct coding initiative (NCCI) and medically unlikely edits (MUE)
- Maximizing incontinent supplies
- HIV drugs without HIV diagnosis
- Medically-assisted treatment - Methadone/Suboxone (buprenorphine) clinics