Health care fraud, waste, and abuse impacts all Americans—from consumers who pay more for their insurance as a result, to employers who face higher costs to provide insurance benefits for their employees, according to the National Health Care Anti-Fraud Association.
The association, which is a partnership formed by private health insurance companies and state and federal government officials, reports that the United States spent $3.6 trillion on health care in 2018, and an estimated 3–10% of that money—hundreds of billions of dollars—was lost to fraud. And that doesn’t count the billions more lost to waste and abuse in health care, according to an analysis in the Journal of the American Medical Association.
Potential Types of Vision Care Fraud
Vision care isn’t exempt from potential fraud, waste, and abuse. For example, an eye care professional could potentially submit the same bills for a patient’s eye exam to both their Medicare Advantage plan and to their vision insurance vendor, says Joseph Nopper, manager of the Special Investigations Unit for Versant Health.
An eye care professional could also overutilize specialized ophthalmic testing procedures, which could result in unnecessary costs for both the insurer and the patient. Or, because they have an established patient’s records at hand, they might submit fraudulent claims to the insurer, even if the patient hasn’t had their annual eye exam, Nopper says.
In addition, a patient could abuse the system by sharing their eye care benefit with friends or family members, he says, or submit a claim for a replacement pair of eyeglasses when they simply want to have a second pair.
Combatting Fraud, Waste, and Abuse
Versant Health works hard to try to combat potential vision care fraud, waste, and abuse, setting up its own Special Investigations Unit. To detect issues, Nopper says, this unit uses data analytics to help identify suspicious patterns and trends. The data analytics are constantly updated and adapted based on investigation findings, risk guidance, and industry trends.
The unit investigates all reports of potential fraud, waste, and abuse received through Versant Health’s email or phone hotlines, internal referrals from other departments, and external referrals, he adds. To try to prevent fraud, waste, and abuse, Versant Health provides training to all new employees and has annual training for all staff members.
Helping Health Plan Executives
Medicare Advantage programs are required by Centers for Medicare & Medicaid Services to have fraud, waste, and abuse prevention strategies.
Health plan executives who show a commitment to fighting fraud, waste, and abuse set the tone for the entire organization, and underscore the importance of detection, elimination, mitigation, prevention, and reduction of these issues. This commitment ensures health plan executives’ fiduciary responsibility to their members, as fraud, waste, and abuse impacts their cost of vision care, according to Nopper.
Teaming up with Versant Health can assist health plan executives as they work to prevent fraud, waste, and abuse in the health care system.