Truven Health Analytics recently conducted a study identifying what it called the six most common factors that drive fraud in American health care. Previous Truven research reported that $125 billion to $175 billion in annual spending in the publicly and privately insured population could be classified as abuse and fraud of the system; the new analysis points to factors it says cost employers $4.93 per member per year in unnecessary payments.

Looking at 11.6 million commercially insured individuals and their dependents at 150 large employers, Truven says these factors ran some $122.6 million in fraudulent cost at those companies:

  •   Schedule II drugs without physician care. ($84.3 million) Truven says more than 20% of patients that received drugs such as Morphine, Ritalin or Oxycodone had no medical visit within 90 days of the receipt of prescription.
  •   Multiple patient visits. ($18.5 million) Some 1.4% of “new patient visits” broke American Medical Association guidelines that they occur only once every three years.
  •   Improper use of diabetic supplies. ($8 million) While only $3.9 million in 2010, the cost of diabetic supplies for non-diabetic patients has more than doubled in two years.
  •   Unbundled psychotherapy/drug management services. ($5.3 million) The two are supposed to be billed together using a code that includes both.
  •   Refills on schedule II drugs. ($5.2 million) Although refills are prohibited by law, nearly 1% of patients on schedule II drugs got one.
  •   Wasteful medical transportation. ($1.3 million) More than 5% of patients and 4.6% of medical transport costs had no associated medical visit.

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