Unnecessary Medical Services
Background
Some common medical services may be unnecessary. Some potential examples include doctors ordering diagnostic tests over and above what would be needed under standard diagnostic protocols, providers ordering tests that use newly acquired diagnostic equipment to help pay for that medical equipment, physicians unnecessarily extending hospitalizations or maintaining higher-cost hospitalizations, providers upcoding services to represent a higher level of care than what was rendered, and referrals to out-of-network or other excessively expensive providers leading to higher consumer and insurer costs. Unnecessary services can lead to higher medical expenses, which lead to higher medical insurance premiums.
Research Objective and Deliverables
The goal of this study is to quantify the prevalence of commonly coded, unnecessary medical services and their impact on overall health care costs. In addition, the study would identify alternative services and protocols that are better-suited both clinically and from a cost perspective.
Target Audience and Impact
Health actuaries working at insurance companies and as benefits consultants will better understand opportunities for providers, employers and health insurers to better manage health care costs, which will assist in provider reimbursement negotiations, claims adjudication, and fraud, waste, and abuse identification and management.
Estimated Cost
$25,000
Estimated Timeline
Approximately 4 months