Jennifer Colamonico
Welcome to HMA’s Vital Viewpoints on Healthcare, where we have concise conversations with experts to explore practical solutions for improving healthcare and human services. I'm your host, Jen Colamonico, and today we are tackling a vital topic: Waste, fraud and abuse in healthcare funding. This is something we hear a lot about. We certainly hear a lot about during campaign season, and it has some real implications for healthcare resources as well as the quality of care.
So we're thrilled to have an expert with us on this topic. Let's dive in. Today we have the opportunity to talk with Jen Bridgeforth with us. Jen is an accomplished healthcare executive with over 17 years of experience in claims billing, compliance and fraud prevention. Jen has worked across Medicare, Medicaid, managed care and behavioral health, helping organizations navigate regulatory complexities while advancing health equity and community care strategies.
In her work, she's also focusing on critical issues like the opioid public health emergency and supporting rural healthcare systems. She's currently pursuing her doctorate exploring the impact of parental opioid abuse on children, showcasing her passion for creating meaningful change in healthcare. Jen, I'm excited to have you with us today, not only because this is a discussion among two Jen's, which doesn't always happen, but because we, have been following your work and, the contribution that you're making here at HMA, we're really just excited to talk to you.
So thanks for being here.
Jennifer Bridgeforth
Oh, yes. Thank you for having me. Super excited to be here and, discuss this topic.
Jennifer Colamonico
So, waste, fraud and abuse is a very common phrase. We hear it from politicians, we hear it on the campaign trail. And it's, you know, it's a real concern. We hear stories in the paper of big settlements with fraud. And so, I guess as you think about your work over all these years, help us kind of parse out the reality, kind of what's the reality and what's the rhetoric?
You know, you hear waste, fraud and abuse and you think, well, of course we want to get rid of that. But, it's more complicated than that. So, talk about your, your perspectives on on how this, this issue really is pernicious within healthcare spending.
Jennifer Bridgeforth
So I think one of the first things, I would like to discuss this is really providing, context to, you know, what regulatory agencies actually mean when they say fraud, waste and abuse. So you often hear those terms and you might often hear them say, be called halfway. But essentially, fraud is an intentional action to obtain payment and use somehow misrepresented the facts, and then attempted to be paid for that service.
And then waste is more, unnecessary cost to health insurance programs and then abuses. It includes, practice areas, and it's not necessarily fraudulent. But it still will result in improper payments. And I think throughout that process, over the years, I've learned that, you know, physicians often struggle to understand where the responsibility falls for, you know, medical coding and billing.
Often when we open these open up investigations, you know, they say, well, I have staff to do that. And I do feel like throughout the time that I've done investigations, physicians don't often understand that the responsibility ultimately lies with them because their name is the one that is on the claim and goes out to the health plan to be paid.
And so I think more so than anything, there is a lack of understanding related to billing and coding. However, I do think it's important that everyone knows that the physician's main focus is always to be patient care. That's where our focus should always lie. Although there is some responsibility related to medical billing, coding.
Jennifer Colamonico
So they're accountable for that bill that gets submitted. But their focus is on the patient care. And so there's almost always somebody else who's entering the code and applying the details on their behalf. So is it sort of their accountable. But they're accountable for a team effort.
Jennifer Bridgeforth
So they are accountable. There's always going to be a medical coder. And then with technological advances, there are system edits that are in place and templates to help that charge be, entered into the system is sent to the health plan, but ultimately, at the end of the day, if there is an issue with that claim, that physician will be the one that is held accountable.
However, there are instances where the physician and his medical coder have also been held responsible for the claims that were submitted. You will often see releases, in the news, like press releases, from the OIG and the Department of Justice. And if you look very closely, you will see that the healthcare provider and their staff members, have been, actually held accountable as well.
So although the physician his name is on the claim, he will be held responsible for that staff members can be, held accountable to, if they have taken part, in the fraudulent behavior.
Jennifer Colamonico
All right. So I appreciate you parsing that out and defining those three, because that, you know, too often it's jumbled together. So they really, really are distinct. Let's talk about sort of the waste part, because that, you know, it's not intentional action. It's not intentional waste. One of my mentors, always would say, you know, one man's waste is another man's income.
So how do we think about waste, which is really probably the political issue. And in an environment where they're looking to cut unnecessary spending, they're going to look there. In your experience, you know, how much waste is really waste and how much of it is just sort of different ways of doing things.
Jennifer Bridgeforth
Sure. I do think there is a certain amount of, of waste in healthcare. And I think, just to, you know, put it in, you know, more simpler terms. So ways that would be things such as unnecessary tit. So if you go to the doctor and you've already been diagnosed with the condition, but that same doctor orders that test again as a way to confirm that you had that condition.
That's an unnecessary test that you didn't even need to have, which results in unnecessary spend to your insurance provider and that insurance provider. You know, it could be we hear a lot about Medicare and Medicaid, but truly, those issues can exist within any health plan. In being a healthcare executive. I have responsibilities related to revenue integrity.
And we would often see, you know, there were times where our provider would, provide services. We will request a medical records, and we truly could not see where that service was medically necessary. For that beneficiary. And in turn, that would result in, you know, an overpayment to that provider.
Jennifer Colamonico
Yeah. So that's interesting because what would drive to retest. Right. Sometimes it's to be able to prescribe a medication or, you know, something that might have been well intentioned on the part of the doctor, but because of our kind of fractured, system and, and, you know, requirements and prior authorizations, you know, things don't always line up, right?
You look at it realistically, it wasn't really necessary, but maybe you needed to check that box in order to check the next box, which, you know, is I feel like part of what we're talking about, we're trying to simplify and standardize and.
Jennifer Bridgeforth
Yes. Yes.
Jennifer Colamonico
Are you seeing less of that over time? Are we getting better at this?
Jennifer Bridgeforth
We are getting better. But I think ultimately it goes back to documentation and something that we used to say all of the time is that if it isn't documenting, it didn't happen. And I think a lot of the time there might be a legitimate reason for the service. However, the service provider did not document it in a way that it is shown in that patient's medical record.
And I've even had discussions with providers and are like, well, I know this patient. I have a very close relationship with this patient. You know, we did this because of X, Y, and Z. The problem is, though, it's not in the medical record and it's not enough to verbalize something. You have to write it down because the physician automatically they're going to be expected to provide records generally within 30 days.
And you can ask for an extension of 15 days. So I think we have, I think Medicare and other payers, they've improved, providers ability to obtain information on what is required. But I do think there's still an absence of physicians having the tools that they need, as far as, you know, their system working for them, their EHR, their electronic health record.
There's more work needed there. But I do think there are technological advances that exist today. I think people are creating them in the hopes that it will help physicians and make the documentation process easier, so that we can ensure that they are paid for the hard work that they did. Sure.
Jennifer Colamonico
Yeah. I mean, electronic medical records, in essence, supposed to simplify that. Do you think that they have.
In some ways, yes. However, I do still think there is work to do. I feel like artificial intelligence is on the rise and truly a way for providers to be helped and assisted throughout the documentation process. But I do feel like there's more work to be done. But truly, there are some amazing, EHRs out there, that work they've worked to help truly help providers in the documentation process.
Jennifer Bridgeforth
Some are better than others. However, I do think there are companies that are making, providers, priority and really listening to them. And even doing focus groups and surveys as they build out software to ensure that the software is meeting the needs of the audience. I think oftentimes, companies can, you know, they'll push a product to market in EHR and then it will suddenly have a ton of patches because the end user is unhappy with it and it doesn't suit their needs.
But I think, as time has gone on, technology companies are truly engaging providers to say, hey, does this work for you? And will this work for you? And, you know, having kind of soft launches so that providers can test and provide real time feedback before it's actually released for everyone to use?
Jennifer Colamonico
That's really optimistic. I mean, EHRs, I think, were intended for this purpose, but they probably really weren't designed with physicians in mind. Right? They were kind of effectively billing tools. So the innovation in that space, as you describe is, you know, hopefully going to going to get us, to a better place, at least in terms of that need for documentation.
What are some examples of waste? You know, I guess maybe what are the most common examples you talked about? Unnecessary tests. But are there huge sums of money out there to be saved? If we could only figure out this one thing. What's your sense of that?
Jennifer Bridgeforth
I do think there, you know, right now, the, the government, you know, they estimate, you know, hundreds of millions of dollars that are lost from fraud, waste and abuse. And you'll hear those dollars provided collectively. Not necessarily like, oh, waste is this amount. That's generally not how they reported out. I do think there are ways for us to mitigate that, but I don't I don't know that we always tell providers how they can mitigate fraud, waste and abuse and specifically waste.
I think that sometimes is like a gray area. Because what one defines as waste truly might not be what someone else does. I think for fraud, just for me being a fraud investigator, you can often see the intention there. You know, a provider, you know, billing for a surgery that, you know, a patient has already had things like that.
And then sometimes you will find that, an action taken by a provider, whether it's a hospital admission, a nurse practitioner, you'll find that action falls in multiple categories in that it's not just fraud. It's not just waste. And it could also be abuse. I think it's hard for providers to really understand what the action they're taking in their day to day.
Is this fraud? Is this waste? Is this abuse because they don't believe that it shows intent. And so really it's like, well, I didn't sit down at my desk on a Monday morning and decide to, commit fraud, but then, you know, they'll go through, you know, the record request process and, you know, the appeals process. And then that final process, which is generally the administrative law judge, and they deemed all the services, included in that medical record request is exhibiting fraud, waste and abuse.
So I think there's a certain point where some would view, fraud, waste and abuse is subjective. However, is the job of Medicare, Medicaid, and then the administrative law judge to really make a determination so that it really, truly is, something that is deemed objective and it will often result in an overpayment.
Jennifer Colamonico
So the fraud part seems to be, really the bulk of it. I mean, is that what you're saying in terms of the dollars saved when they're projecting it? It's really the fraud that's it's causing that loss of revenue or loss of dollars.
Jennifer Bridgeforth
I do, I think that and then you like when you hear about it in the news, it's a discussion about. Right. You don't hear a ton about ways. You don't hear a ton about abuse. There's the focus on the fraud that is occurring. And I think when people hear that word, they think, oh my gosh, this is so awful.
And granted, there's nothing good about fraud occurring in the Medicare Medicaid program. It is absolutely not. However, I do think, people need to understand the fraud. It doesn't matter if there was any type of intent there. If the fraud occurs, it will result, in an in an overpayment. And I think when legislative agencies have these talks, specifically CMS and OIG, there is a huge focus on fraud.
And not necessarily the others. Not saying that they are out there and they are occurring, but what makes the news is fraud.
Jennifer Colamonico
Yeah. So the part about the waste is that more political rhetoric versus the reality.
Jennifer Bridgeforth
I you know, it's hard it's really hard to gauge. I do think there's some political rhetoric there. I do think it is happening. And I do think it is important from a compliance perspective. But I think when legislative agencies and regulatory bodies are having these discussions, such as, you know, the OIG, there is a lot of focus on fraud.
If you were to go out and search right now and you know, Google anything, from the OIG, generally you will see these enforcement agencies focus largely on fraud, or you will see the word scheme, when they are discussing anything related to a compliance issue, from a provider. So I think for me, if you're reading the news and you hear the word waste, are you really going to pay attention?
Probably not as much. But if you see the word fraud, you see that word fraud. With scheme, you might perk up a little bit and read, you know, focus a little bit in on that story. And what is there. So I think, it really is work. Fraud is a and it's an attention grabber. It makes the reader want to keep going, whereas waste and abuse, maybe not so much.
Jennifer Colamonico
Yeah. Wait, I think waste is an interesting word because I feel like there's, you know, baked into the American psyche is this kind of assumption that government is inefficient and this assumption that things are wasteful. It's sort of this broad brush stroke, you know, accusation that can be painted on both sides from any direction. And people just kind of nod their heads, but they don't.
It's not entirely particularly meaningful. It's a general assertion. Whereas fraud, it's like, oh, there's a bad guy doing a bad thing, or, you know, bad woman, bad person, whatever it is doing a bad thing. Clear good guys, bad guys. We get that right. It kind of fit to use that rhetoric. But the waste is, you know, it's it's I think it serves a different purpose, which is why I'm always, you know, kind of interested when when you roll it together and then, and then somebody says, we're going to tackle this.
Well then what does that mean? So then what is what is our what is our action. You know, is it more ironically more government? You know, like OIG staffing up, the OIG staffing up the enforcement agencies. That's more spending. But arguably, you know, to find the bad guys. So, you know, we can maybe get behind that. How do you know, how do we tackle waste at a at a at a broad level?
Jennifer Bridgeforth
I think you raise a very good point. Everything that you said, I, I completely agree with and I think it's, it's valid to question, you know, waste and, you know, where does it fit in the, in the grand scheme of things because it's really it's one of those things where I don't feel like as if the public we hear that word waste.
But really, what does that mean for health insurers. And I think we definitely overall I think there is some more work to do because I do think waste occurs is just not at the forefront for me. I feel like when you hear about it, I don't feel like, again, regulatory bodies are focused on that. Now the I think when consumers, you know, like you or myself, we hear about waste, I think it's it might be a little bit different.
Maybe the implications are different for us. But I think for regulatory agencies and even for, you know, national bodies, the focus is on the fraud and not on the waste. And I don't have all of the answers, but I think that, we're going to see probably more focused where there is a, you know, now that we have a new administration, you know, maybe there will be a different focus on, you know, the waste in that abuse and less on the fraud.
But I think that if you were to go out and now there's going to be a lot of focus on fraud in the words fraud scheme. And that has traditionally been the focus. And unfortunately, I don't know what it will take for that focus to change. I'm just I'm not sure.
Jennifer Colamonico
Yeah. It's less you're right. Fraud has a starting and end point and you can say check. Mission accomplished. Right. Whereas waste is complicated. healthcare is complicated. Yes. And and so, you know, when we think about all of the ways in which we're trying to reduce waste, you know, what is it that patients need to get healthier more quickly?
Right? And is it more tests? Is it, you know, other interventions that, frankly, maybe cost more money but are maybe more effective? Yeah, people aren't all the same. So it's tough to crack that.
Jennifer Bridgeforth
I agree. And I think as we focus more on, you know, value based payments and not like, so right now, traditionally the way that providers are paid is the more you build this code, the more your pay. But I think is we see a shift, into value based payments. I think that that is going to decrease in general.
Fraud, waste and abuse will hopefully go down when you start rewarding, providers for, hey, we're going to pay you, you know, based upon the health of your patients. Right? And so I think when you have, you know, when you add the value based payment piece that can truly help with healthcare expenditures overall and not just decrease the fraud, waste and abuse, because when you tell someone, hey, if you build this code ten times, you're going to be paid this amount.
It may be a small percentage of providers that might decide it's worth their risk to overbuild for those services over code for those services, over utilize, those codes because it results in higher payments. Looking forward to seeing CMS coming up with more value based, initiatives and, you know, managed care organizations, coming up with more value based solutions so that really the patient is the forefront, the patient is the sinner.
There has to be some focus on reimbursement, but move, toward that patient centered care. And, and truly reward providers for, you know, having healthy patients, healthy patients and, and prevention, and I think in value based care, there's a huge opportunity for prevention and for there to be focus on, you know, prevention as it relates to, you know, taking a more holistic approach to healthcare.
Jennifer Colamonico
Yeah, that's so important. And, you know, we've been talking there's been a value based care conversation in healthcare for a very long time. And yet, and we've made considerable progress and yet not enough right where we haven't gotten past the hump, of sort of being the majority of payments. And from your point of view, in the, in the clinical settings you've worked in, you know, what do you think is the biggest obstacle?
I mean, is it the physician resistance? Is it the infrastructure where, you know, why haven't we moved faster when those outcomes I think everybody could agree are good. Right. So why haven't we moved faster to changing how we pay for things.
Jennifer Bridgeforth
So, you know, I think I think change is, is hard, for, for any industry. And when you've been doing something the same way for so long, it's really hard to shift. One of my closest friends is a nurse practitioner, and, you know, just having, we have a lot of discussions about health insurance and reimbursement and things like that.
And I think, you know, one of her concerns, and truly, this truly allowed me to see it from a provider perspective. And she said that when you think about value based payment and you look at your contract as a provider and you see that you are going to be, rewarded for patient outcomes, she said it could be a way for providers to essentially, move away from assisting the patients that they might be resistant to, you know, certain care modalities and be they might be, just resistant to care in general.
So they care continues to decline, which essentially makes their providers quality scores go down because they aren't meeting those marks that the, health insurance has placed in their contract for them to receive, you know, those, quality incentive payments. So, you know, this is really a different perspective. And I think there might be some resistance from providers because of that, because for quality incentive payments, some of it is based upon patient behaviors, beneficiary behaviors.
If they're not, you know, really working with the provider, to ensure that they receive proper care because, I mean, honestly, I've been one of those patients before, you know, being diagnosed with a chronic illness early on, I was more concerned about, you know, being in college versus going to the doctor and continuing care. And so even with elderly patients, they might be a little bit resist it to, you know, hearing that they have to change eating habits and things like that, which all of that can impact quality insulin payments.
And I think a lot of times, you know, there are things put in place in this industry and we don't always make them through. So there might be some resistance from just providers in general. And a lot of provider organizations do come out, with their opinions. And they will often, you know, during that public comment period, they will often, you know, reach out to see a mess about their concerns.
And so CMS will sometimes take those concerns into consideration. And so some of that resistance can come from various parties within the healthcare delivery to not just providers.
Jennifer Colamonico
That's so interesting. And it kind of takes you back to the waste conversation, because, you know, if a doctor has a challenging patient, as you know, they all do, right? There's humans are complicated and not everybody follows the rules. And yes, you have a complicated patient and you're trying to throw a bunch of things at them to try to make them healthier.
You can't. You have a limited ability to make that patient healthier, depending on the situation. And, and so in retrospect, somebody might say, well, that's wasteful. You know, you did these things that didn't have a real clear impact. And but it's like if you're the doctor, you're trying anything at this point. Right? So the risk is not always, you know, wasted able to take that risk with certain patients.
Jennifer Bridgeforth
Absolutely. And I think as we continue to have these discussions, we have to really go back to documentation. When providers have patients that are difficult or they have to, you know, complete a test more than once, it is really important to document the reasons why it is important to document any service that has to be completed more than once.
And because what you don't want is for it to look like that service was never rendered or, appeared that, you know, star service wasn't that expensive. So, you know, I want to do a more, you know, expensive test. You never wanted to, appear that you are up coding of costly billing. So at the end of the day, a lot of this goes back to documentation.
You have to document it. If it wasn't documented, it did not happen.
Jennifer Colamonico
Based on your experience and your observation of these different dynamics, if you had a magic wand and you could wield it in any way to improve of, the circumstances that we're talking about here, how would you how would you wield that wand?
Jennifer Bridgeforth
Oh, man. So I think for me, the one thing that I would love to do is, require some type of intensive, coding and billing forces for healthcare providers. Generally, by the time a provider would get to me on the, fraud investigation side or on the side where I was attempting to assist them in navigating, a medical record request that I received from, the the Department of Justice or CMS.
They weren't informed about documentation and, you know, revenue cycle and things like that. So I would love for providers to be required to, you know, at some point, take some type of extensive coding and billing course revenue cycle management. Because generally when you're in medical school, the primary focus is, you know, patient care. So when you have your curriculum that's the primary focus.
But in reality, when you go out into the world, you are going to be responsible for billing and coding of services. And a lot of times these rules can be complex, and the provider lacks the knowledge on that side because they've spent their time doing what they were supposed to do, which is patient care. So I would love so my magic wand would be that there's a requirement for some type of coding and billing and revenue cycle management.
So the providers are truly well informed, and they are informed enough to know the questions to ask. Someone like me, you know, when they when they need assistance because I'm truly used to. Hey, by the time some providers got to me, they had an overpayment from CMS. There was $3 million, you know, or, you know, they're on the verge of CMS conducting some type of extrapolation against their claims.
And at that point, the provider is frustrated and anxious, and truly trying to figure out how to navigate a system that they haven't been that familiar with in the first place.
Jennifer Colamonico
Yeah, they're not really trained to be business leaders, but they are rather, they're whether they're independent practice or even in a group practice, they have a business responsibility. Yes. And so and you're right, they're not really well prepared for that. And it's Byzantine and it's complicated. And it's funny when you say, like, they should have a, a class on coding and billing.
I'm sure every physician, just like the hair went up on the back of that. That's right. Like the last thing a physician wants to do, but that's what they're responsible for is business owner. So how do you make that? That's a great it's a great magic wand. Right. Because how do you use relevant and easy and, and support them in making better decisions.
Jennifer Bridgeforth
Yes. And I truly I have a passion for provider education. Is something that I've done for many, many years. And although I have a passion for provider education, I truly feel like it is something that I should be well-versed in prior to them ever speaking to me, because there's always something that cause, you know, a physician practice to seek, you know?
Yeah. Or hospitals seek me out to educate physicians. It's usually that a payer has contacted them and said, you are an outlier among your peers, and you need to shape up. And so they should be well informed before that, not on the back end, prior to more proactive instead of react dudes.
Jennifer Colamonico
Yeah. And I guess that goes back to sort of the intentionality, right? I think I, I conclude from this conversation, you know, fraud, abuse, that's clear cut. Good guy, bad guy. Go find him, you know, work it out. But really, in terms of, you know, the the intentional misbehavior, it is very subjective and we as a society are not really doing the best job to support physicians in being successful there, in terms of providing them with the information, but also, you know, designing payment systems that are not as onerous.
I mean, I I'm really glad you brought up value based care, right? There are a lot of ways we could do it where it wouldn't be as complicated and it might have better outcomes so that, you know, they still need to take up and take up their responsibility to navigate properly. But we can also make it easier for them.
Jennifer Bridgeforth
So absolutely can definitely make it easier. And I'm, I'm hoping that there's a day where it is easier and it's not so cumbersome for them because truly, I want physicians and, you know, nurse practitioners, all healthcare providers, I want their primary focus to be on patient care, because at the end of the day, if patient care is a focus and we can improve patient outcomes, then healthcare expenditures will ultimately decrease.
Jennifer Colamonico
Yeah. And that's we'd all love to be able to see that.
Jennifer Bridgeforth
So yes.
Excellent. Anything else that that we didn't talk about that's important for people to understand this issue.
Jennifer Bridgeforth
I would like to reiterate if it is not documented, it did not happen.
Jennifer Colamonico
I like it, Jen, thank you so much for your time today and for all the work that you do. And, we really appreciate you.
Jennifer Bridgeforth
Awesome. Thank you so much and I'm so glad you guys had me on. It was a joy.
Jennifer Colamonico
This episode of Vital Viewpoints on Healthcare is sponsored by H.M. Information Services. HMAIS is a subscription based service that provides state level data on publicly sponsored programs like Medicaid from the latest managed care enrollment, market share, and financial performance data to up to date RFP calendars and state by state overviews, HMAIS has all the information you'll need to power your initiatives to success.
This podcast was produced by myself, Jennifer Cola Monaco along with Tiffany Mackenzie in collaboration with our guests. The content is the property of Health Management Associate.
