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How Fraud Impacts the Field of Healthcare Administration and What Can Be Done

Use training and technology to fight fraud.

Healthcare fraud costs tens of billions of dollars—or more—annually, according to estimates by the National Health Care Anti-Fraud Association (NHCAA).1 For consumers, the impacts of fraud are clear: Healthcare fraud results in reduced benefits, higher out-of-pocket costs, unnecessary procedures and prescriptions, and more expensive insurance premiums. The U.S. Department of Justice is taking action: In September 2021, criminal charges for healthcare fraud were announced against 138 defendants, including 42 licensed medical professionals, nurses, and doctors. Their combined, alleged fraudulent actions resulted in an estimated $1.4 billion in losses.2

The staggering financial impact of healthcare fraud is clear. However, preventing fraud—while also providing quality care—is not a simple task. Healthcare administrators must pursue fiscal integrity while also ensuring patients receive the best care possible, as quickly as possible. Meanwhile, administrators must navigate local, state, and federal regulations while also staying abreast of shifts in Medicare and Medicaid policies and changes to the Affordable Care Act. Accurate documentation and appropriate coding are keys to preventing healthcare fraud. As a healthcare administrator, there are things you can do to help combat fraud.

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Provide training.

As a healthcare administrator, you must stress the importance of accurate medical record documentation. Accuracy is critical in providing patients with timely, quality care, and it also ensures that neither undercoding nor overcoding occur. Medical professionals need to document the patient’s condition and the services needed to treat that condition. That information will then support the appropriate coding. You can make this training part of the onboarding process for physicians and medical personnel, plus offer annual or biennial refresher trainings.

Implement computer-assisted coding (CAC).

Use CAC software to automatically generate medical codes based on medical documentation, in alignment with standard coding principles and guidelines. Not only does CAC help reduce miscoding, it also speeds up the coding process. Additionally, you can create an audit trail by using CAC software, which can help uncover errors as well as fraud.

Use data analysis to find fraud.

Data analysis tools can help identify fraud. You can set up rules, and analytic tools can sound the alarm when data falls outside the rules’ boundaries. For instance, you can set up an alarm for instances where a healthcare provider submits a code for a procedure outside of his or her scope of expertise. That alarm will automatically lead you to the data you need to review, sparing you from combing through an entire database full of codes to search for anomalies.

Healthcare administrators ensure that hospitals and other healthcare organizations provide quality care to their patients. According to U.S. Bureau of Labor Statistics data, the role of medical and health services mangers is expected to see a growth rate of 32% from 2020 to 2030.3 If you’re interested in fighting healthcare fraud and joining the growing field of healthcare administration, consider earning your Master of Healthcare Administration (MHA).

Walden University is one of the top granters of healthcare administration master’s degrees in the U.S.4 The accredited university’s online master’s in healthcare administration degree program is aligned with the National Center for Healthcare Leadership (NCHL) model. Walden’s MHA curriculum combines industry knowledge with practical competencies for outstanding healthcare leadership.

You can choose Walden’s general MHA degree program or one of four specializations: Leadership and Organizational Development, Population Health, Social Entrepreneurship and Innovation, or Systems and Policy. All of Walden’s master’s in healthcare administration programs are available as online, course-based degree programs. Walden’s general MHA degree is also available in a second format, as a competency-based degree program, called Tempo Learning®.

Tempo Learning® allows you to study at your own pace and move ahead by completing competencies—the skills, knowledge, and abilities that demonstrate your progress. The Tempo Learning® competency-based format is all-you-can-learn: You subscribe to three-month learning periods, and the number of competencies you complete during that time is up to you.

No matter what format or specialization you choose, Walden’s MHA degree program can help prepare you for a rewarding career in healthcare administration.

Walden University is an accredited institution offering a Master of Healthcare Administration (MHA) degree program online. Expand your career options and earn your degree using a convenient, flexible learning platform that fits your busy life.

1Source: www.nhcaa.org/tools-insights/about-health-care-fraud/the-challenge-of-health-care-fraud/
2Source: www.justice.gov/opa/pr/national-health-care-fraud-enforcement-action-results-charges-involving-over-14-billion
3Source: www.bls.gov/ooh/management/medical-and-health-services-managers.htm#tab-6

Walden University is accredited by The Higher Learning Commission, www.hlcommission.org.

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