Managed care requires new ways to find fraud

Article Abstract:

The advent of a health insurance market dominated by managed care will require different fraud-prevention techniques. The typical fraud investigation that is based on fee-for-service medical care is inadequate. Managed care contracts should be constructed to address the most common types of fraud, such as billing for services not rendered, upcoding and kickbacks for referrals. Some of the fraud in these schemes is difficult to document, and investigators will need better medical knowledge.

Column, Prevention, Insurance fraud

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Holding the line on behavioral health costs

Article Abstract:

Employers are contracting behavioral health carve-out companies to manage mental health and chemical dependency costs. Carve-out firms have developed several strategies to control costs, including developing preferred provider panels, requiring concurrent utilization reviews to provide evidence of medial necessity and requiring precertification for intensive services.

Pension, health, and welfare funds, Employee Benefits Management Svcs, Third Party Administration of Insurance and Pension Funds, Medical Insurance NEC, Employee benefits management services, Mental health benefits

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Managed results programs coordinate benefits delivery

Article Abstract:

Employee benefits programs could be less costly if they were operated as a managed results program. Disability, return-to-work programs and medical care would be connected rather than managed by several different departments within a company. Many companies have each facet of their benefits programs managed by different insurance firms.

Innovations, Insurance industry, Contracts, Employee benefits

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