ABSTRACT
Economic and social forces combined with imprecise treatment standards are creating a virtual explosion in employer costs attributable to mental and chemical dependency disorders. To develop appropriate programs for managing these costs, the forces that drive utilization must be understood.
Subject(s)
Employer Health Costs/trends , Health Benefit Plans, Employee/statistics & numerical data , Insurance, Psychiatric/statistics & numerical data , Mental Health Services/statistics & numerical data , Substance-Related Disorders/economics , Adolescent , Adult , Aged , Child , Cost Control/methods , Female , Health Benefit Plans, Employee/economics , Humans , Middle Aged , Substance-Related Disorders/therapy , United StatesABSTRACT
Plan design holds the key to managing mental health and substance abuse costs, Ms. Pflaum points out. She explains that utilization review, EAPs, HMOs and PPOs, and carve-outs can be useful in the process.
Subject(s)
Health Benefit Plans, Employee/economics , Managed Care Programs/economics , Mental Health Services/economics , Substance-Related Disorders/economics , Cost Control/methods , Employer Health Costs , Humans , Industry/economics , Insurance Claim Review , United States , Utilization Review/economicsABSTRACT
Each year health care fraud drains millions of dollars from employer-sponsored health plans. Historically, employers have taken a rather tolerant view of fraud. As the pressure to manage health plan costs increases, however, many employers are beginning to see the detection and prosecution of fraud as an appropriate part of a cost management program. Fraud in medical insurance covers a wide range of activities in terms of cost and sophistication--from misrepresenting information on a claim, to billing for services never rendered, to falsifying the existence of an entire medical organization. To complicate matters, fraudulent activities can emanate from many, many sources. Perpetrators can include employees, dependents or associates of employees, providers and employees of providers--virtually anyone able to make a claim against a plan. This article addresses actions that employers can take to reduce losses from fraud. The first section suggests policy statements and administrative procedures and guidelines that can be used to discourage employee fraud. Section two addresses the most prevalent form of fraud--provider fraud. To combat provider fraud, employers should set corporate guidelines and should enlist the assistance of employees in identifying fraudulent provider activities. Section three suggests ways to improve fraud detection through the claims payment system--often the first line of defense against fraud. Finally, section four discusses the possibility of civil and criminal remedies and reviews the legal theories under which an increasing number of fraud cases have been prosecuted.
