Healthcare provider investigates 3,000 claims annually for fraudulent or mistaken billing and recovers payment in 30-50 per cent of cases, writes MARTIN WALL, Industry Correspondent
THE STATE’S largest health insurer, the VHI, has recouped nearly €4 million from hospitals and doctors in the past year on foot of investigations into allegations of erroneous or false claims.
A confidential report on the VHI, carried out by the consultancy firm Milliman on behalf of the Department of Health – which is expected to be published this week – says that the company investigates about 3,000 claims annually “for fraudulent billing, recovering payment in 30 per cent to 50 per cent of cases”.
“These are claims where the member has alerted VHI to potential fraud after reviewing the invoices received by VHI for their treatment. Recoveries are €1.1 million for 2010 year to date and are projected to be €2.5 million for 2010 in total.”
However, in a statement this week, the VHI said its special investigations unit (SUI) had actually recovered €3.9 million last year.
“Last year, there were approximately 2,000 contacts to the SIU by VHI Healthcare customers regarding claims paid on their behalf. The most common anomalies identified were:
Incorrect accommodation fees being invoiced by a hospital, ie private room billed where the patient occupied a semi-private room.
Incorrect consultant charges, ie charges being raised for cancelled surgical procedures.
Private fees being raised for patients who were treated in a public capacity.
Incorrect data being entered on a claim form by providers.
“Once errors are identified, VHI Healthcare notifies the provider in question and deducts the monies involved directly from the provider. They are also asked to ensure that their processes are amended to prevent any recurrence.
“If there are a number of queries or repeat occurrences of anomalies with a particular hospital or provider, an audit is conducted to identify the extent of the practice, the level of monies to be repaid to VHI Healthcare and design processes to prevent any recurrence of inappropriate billing.”
VHI said its special investigations unit was currently carrying out investigations into a number of areas including long-stay hospital admissions, to ensure the appropriateness of admissions to acute facilities from a medical perspective, and also day-care charges in a number of public and private hospitals, to ensure these were being invoiced appropriately.
“VHI Healthcare is looking at extending the role of the SIU as it plays an important role in helping to manage the costs of the organisation.
“The work conducted by the SIU has allowed VHI to recover a significant amount of money but has also allowed us to work with hospitals and providers to improve the systems that they have in place to ensure the appropriateness of their invoicing.
“VHI Healthcare processes over half a million claims each year and it is vital, particularly in these tough economic times, that customers continue to help us ensure every cent we pay out on their behalf is paid out correctly.”
The company said customers should be vigilant when examining their claims statements which outline the details of the treatment they have received.
“Customers are asked to notify the SIU – in the strictest of confidence – if they think that there is a mistake on their statement and that VHI Healthcare has been charged for accommodation or treatments not received or if they are aware of any incident of incorrect/inappropriate billing,” the company said.