Effective fraud control programs combine predictive modeling and other detection analytics with clinical review of associated claims and medical records. This helps spot suspicious medical claims and rule out false positives. When this is done prepayment, health plans and other payers can more efficiently prevent and control healthcare fraud. Pay and chase is avoided. Once the payer is provided with suspicious analytic and clinical information, the next step is to more closely examine associated medical records.
There are many red flags for fraud and abuse in medical records. The seven examples noted below provide a high level overview of this complex arena.
1. Provider notes are exactly the same for multiple patients. Medical visits vary by human nature. A patient visit with a provider will typically not be the same as the next patient seen. When a provider supplies the exact same documentation for many patients, this is a red flag.
2. Medical charting is materially changed after the date of treatment. Sometimes providers learn of a legal challenge to a patient care encounter such as fraud or potential malpractice case and they get nervous. There is a temptation to go in and make changes to provide more detail or enhance the records to favor the provider's perspective. The catch here is that malpractice attorneys often obtain copies of the medical records before they place anyone on notice of the claims. Thus they have the original records. Once the originals are presented and compared to the "enhanced" records, the attorneys often use this against the providers. This can be falsification of medical records for which many providers have lost their license.
3. Charting alleges treatment on an unlikely day. Absent an emergency, it is unlikely that routine medical care is given on Sundays, holidays, or around a catastrophic weather event such as Hurricane Katrina. For example, on June 2, 2010, a New Orleans physician, age 78, was sentenced to 12 months of electronic confinement and fines more than $755,000. His crimes included billing the government for care allegedly performed after Hurricane Katrina, when his office was closed.
4. Charting notes are inconsistent with x-ray, lab or pharmacy data.
On July 30, 2010, operators of a Miami clinic pleaded guilty to defrauding Medicare in the amount of $13.7 million by submitting false claims for HIV infusion treatments that patients either did not need or did not actually receive. This is a good example of a situation where there was insufficient medical records evidence to corroborate the alleged care provided.
5. Medical records allege the same patient was in two places at the same time. For example, if records reflect that the same patient had care at the same date and time, such as chiropractic care in Tacoma, WA, at the same time there is alleged treatment at an ER in Seattle, WA, this cannot really be the case. This is a red flag for fraud and for medical identity theft.
6. Patient recollection of care is inconsistent with medical records. Often the first step in an SIU investigation is to contact the patient to confirm the nature and extent of care provided. The patient's recollection is then compared to the medical records. If the patient had no such care or different care this is a red flag for fraud.
7. Medical records may reveal treatment protocols that do not comport with best practices or prevailing standards of care, or exhibit non-FDA approved treatment.
On June 5, 2009, a federal complaint was filed in the U.S. District Court of New Mexico against an operator of a Las Cruces clinic for conspiring to defraud patients by falsely diagnosing and "treating" for Lyme disease utilizing a medical device, and an intravenous cocktail, both of which were non-FDA-approved. Additionally, these methods are not recognized as legitimate diagnostic or treatment protocols for Lyme disease.
An integrated approach to fraud control that includes these and other red flags for fraud in medical records is beneficial to an effective fraud control program. Industry experts agree that measures for early prevention and detection of health care fraud save health plan dollars that could otherwise be spent caring for legitimate patients. An effective fraud control program is an important tool for catching these red flags and fighting medical fraud. The ever-evolving "creativity" of those engaging in medical fraud and abuse is often reflected in medical records. Identification of red flags in the context of a medical fraud investigation helps detect medical fraud with solid evidence. This helps direct scarce medical resources toward patient care and away from the fraudsters.
Christie Moon is the chief compliance officer for HealthCare Insight (www.hcinsight.com). Christina Matsiga is a clinical investigator at the company.