As Healthcare-Billing Fraud Escalates, Argus Ramps Up Watchdog Efforts

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Healthcare-billing fraud is a growing problem in the U.S. With his company, Argus Claim Review working on behalf of employers to cut healthcare costs, Tom Doney has become a leading advocate for cost containment and accountability in healthcare. Here, he explains how providers commit healthcare-billing fraud and how Argus saves employers thousands through its diligent watchdog efforts. Argus also shares five tips for employers to avoid excess medical claim charges at http://argusclaimreview.com/uploads/5_tips_for_employers_FINAL.pdf.

On average, Argus saves U.S. clients just over 46 percent on billed charges per claim reviewed.

Healthcare-billing fraud is a growing problem in the U.S. With his company, Argus Claim Review working on behalf of employers to cut healthcare costs, Tom Doney has become a leading advocate for cost containment and accountability in healthcare. Here, he explains how providers commit healthcare-billing fraud and how Argus saves employers thousands through its diligent watchdog efforts. Argus also shares five tips for employers to avoid excess medical claim charges at http://argusclaimreview.com/uploads/5_tips_for_employers_FINAL.pdf.

To most, trying to interpret a hospital bill or claim statement can be like reading a foreign language. After the dizzying experience of going through a few lines of diagnostic codes and descriptions, it can be tempting to give up and simply trust that all services have been billed accurately.

But the extra work is often times well worth the effort.

As healthcare-billing fraud continues to affect unsuspecting employers, the reality is that paying these bills without careful scrutiny can result in drastic overpayments by companies.

Tom Doney, CEO and co-founder of Argus Claim Review – a national company with offices in Wisconsin, Nebraska, Oregon and Colorado – has taken the lead in righting this wrong. Focused on cost containment in healthcare, Doney has been summoned to testify in front of the U.S. Department of Labor and serves as a leading spokesperson on the issue.

Though many billing inaccuracies turn out to be honest mistakes, Doney says healthcare-billing fraud and overcharging can take many forms.

“It can be as simple as double billing a single service to as complex as intentionally misrepresenting the type of service provided, when it was provided or the identity of the patient,” Doney explains. Other examples include billing for services or supplies that were never provided, altering a condition or diagnosis, inflating prices or unbundling services. He says upcoding, providing kickbacks or performing unnecessary tests/treatments with the sole intent to generate more revenue are more ways to sneak in extra charges.

While most providers would never think of purposely overcharging a patient, it’s the small percentage of others who are perpetuating the situation. And it results in rising healthcare costs with a significant ripple effect, since larger claims lead to larger premiums for employers and employees. It all contributes to spiraling costs, which some projections show are expected to climb to $3.6 trillion by 2014.

With today’s dramatic economic struggles, that’s something nobody wants to see happen.

To combat fraud and emphasize cost containment, Doney and his team have implemented Argus Claim Review, a solution for guarding against costly billing errors and claim deficiencies. Named after Greek Mythology’s 100-eyed guardian who never sleeps, Doney explains, “With our system, we are constantly on the lookout for claim errors and vigilant in our efforts to catch them, correct them and uncover savings on behalf of employers.”

Things that can trigger a more intense claim review by Argus include network claims totaling over $10,000, dialysis and chemotherapy treatments, chronic pain management, multiple surgeries and anesthesiology.

Whether it’s a single dose of pain medication billed at 20 times the norm or the X-ray that was never performed, Doney is confident that his team will discover any inaccuracies.

The efforts are paying off. “On average, Argus saves U.S. clients just over 46 percent on billed charges per claim reviewed,” Doney reports. To show how this is done, Argus shares a healthcare-billing fraud prevention tip sheet on five of the top medical claim areas employers should monitor, including medical coding, charge accuracy, medical necessity, plan specifics and unbundling/upcoding.

For examples of everyday savings uncovered, Argus features several case studies on its website. Doney points out one example where Argus saved an employer over 75 percent on a large claim. In that instance, a Veteran’s Administration hospital charged $101,575.28 for a four-day stay; Argus researched the national pay rate for the Diagnosis Related Group (DRG) and ran claim data to see what Medicare would pay hospitals in a 50-mile radius, thus lowering the bill to under $23,000 and saving the employer a staggering $78,664.86.

What happens when healthcare fraud is, in fact, discovered? Oftentimes, claim specialists work with billing agencies to indicate errors and negotiate the appropriate charges on behalf of employers. Depending on the situation, providers can also be reported and investigated.

So rather than filing a claim away before closer review, companies should think of what the 100-eyed guardian and his team of sidekicks would do. The potential savings could mean thousands to a company’s bottom line.

Headquartered in Appleton, Wis, Argus Claim Review features one of the industry’s most comprehensive systems for guarding against error and fraudulent billing. For more information, visit http://www.argusclaimreview.com.

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Lori Van Handel
Willems Marketing
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