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How Much are Fraud, Waste, and Abuse Costing You?


By Jody Amodeo/Friday, July 19, 2013
Jody Amodeo imageTypically, we think of fraud, waste, and abuse as being confined to Medicare and Medicaid. However, recent findings show it is widespread in the commercial insurance population as well. In fact, results obtained from the Truven Health MarketScan® Commercial Database, found the estimated overall impact of six common claims scenarios alone is $122.6 million in over-payments in one year – or nearly $1 million annually for each of the organizations in the study. These issues are not limited to these six algorithms, but help shed light on the nature and extent of the problem in the commercial population.

What are those six algorithms and what can we do?
Here are the six algorithms we analyzed and the over-payments associated with them:

  • Multiple new patient office visits for a patient with the same provider in three years – $18.5 million
  • Diabetic supplies for members without a diabetes diagnosis – $8 million
  • Medical transportation trips to nowhere – $1.3 million
  • Schedule II drugs without physician care – $84.3 million
  • Refills of Schedule II drugs – $5.2 million
  • Unbundling of psychotherapy and drug management service – $5.3 million
Just think, here at Truven Health, we have hundreds of algorithms in our database. In just six of them, we’ve found $122.6 million in savings. How much more could we save the industry, if all of the algorithms were implemented in all the country’s organizations to detect overpayment patterns? With an estimated $600 to $850 billion of annual U.S. healthcare spending attributable to waste of some kind, surely our advanced predictive models and algorithms could help identify and reduce a huge amount of claims waste, fraud, and abuse.

Learn more and contact us
For more information on the six key algorithms for commercial payers, download the complete Payment Integrity Analysis. Please contact us with questions, or to learn more about our payment integrity solutions.


Jody Amodeo
VP Practice Leadership

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