Challenge description

Each procedure performed by a doctor or other healthcare provider has an assigned code that allows them to issue an insurance bill. Different codes correspond to different procedures, so they may have higher or lower costs. As long as the provider uses the correct code, it is paid for based on real services and procedures.

 

Increasingly, however, we are dealing with the phenomenon of upcoding, which consists of showing rates higher than the costs of service actually performed in the settlement of medical services. This is an unlawful practice used by suppliers who try to cheat the system to get more money than they negotiated. It results in increased costs for individual patients and – even worse – may even negatively affect their health. Providing false information about medical records may affect the patients’ future ability to insure.

 

How can this phenomenon be prevented from spreading?


The optimal solution is …

The optimal solution is a module for detecting fraud in the field of health services settlements financed from public funds in the perspective of the so-called upcoding and unbundling.

 

Key system functions:

  • Finding the system abuse and showing what it looks like.
  • Indication of how the correct settlement should look like (complete information to carry out the inspection).
  • Indication of the amount of potential abuse.
  • The ability to export files to Excel or a dedicated report.

 

Implementation of effectiveness parameters:

  • Increasing the level of detection of irregularities in the settlement of health services reimbursed from public funds confirmation in the NFZ control of an incorrect settlement of a given group of benefits.
  • confirmation in the NFZ’s check up of the validity of the justification for the diagnosis of irregularities presented by the applications.
  • Increase in the number and value of detected fraud.
  • Indication of JPG(DRG-diagnosis Related Groups) in which type 1 and type 2 abuses occur.
  • Increased migration of benefits to cheaper Diagnosis Related Group.

Expected implementation budget: PLN 300 000

Expected implementation time: 4 month


Are you ready to solve the problem?

Great job! Below you will find some useful information:

  1. How to apply for the contest?
  2. Why anonymity in the competition is so important?
  3. Ministry of Health’s challenge regulations.

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