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How to detect fraud in medical records


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Medical records are often tampered with by providers for some purpose of their own. This article lists some red flags to watch out for in healthcare records.

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How to detect fraud in medical records

  1. 1.                                       1­800­670­2809 How to Detect Fraud in Medical Records Medical records are often tampered with by providers for some purpose of their own. This article lists some red flags to watch out for in healthcare records. Health plans and other payers need to be wary about falsification of medical records, whether intentional or inadvertent. Government as well as private payers have efficient fraud control programs to identify fraud during the medical record review process, and thereby prevent wrong payment of medical claims. When a payer receives medical claims and clinical information that seem suspicious, a review of the pertinent medical records is carried out for more detailed understanding. “Every Contact Leaves a Trace” – Watch Out for These Pointers                                       1­800­670­2809
  2. 2.                                       1­800­670­2809 As Edmond Locard, the well-known criminologist stated, “every contact leaves a trace” or in other words, a criminal leaves some clue or other at the scene of crime, which helps in solving the crime. Similarly, abused medical records carry indelible signs of the abuse that reviewers need to watch out for. So, what are these warning signs? • Changing the medical record after the date of treatment: Now why do practitioners indulge in this kind of falsification? It is mainly done in the wake of an impending fraud or medical malpractice case. The modifications are made to favor the provider’s perspective. • Medical records are the same for multiple patients: When documentation remains the same for different patients, it is definitely irrational. • Medical records show the patient was at two different places at the same time: This is a pointer towards fraud/medical identity theft. A patient cannot be at two different locations at the same time receiving treatment. • X-ray, lab and pharmacy data do not support the data in the medical records: This happens when certain providers submit claims for treatments that patients did not need or did not actually receive. • Medical record data does not tally with patient recollection of care: This is another indication of fraud, when the patient denies having received such care. • Medical records list treatments provided on unlikely days: Except in emergency cases, it is unreasonable to expect that patients will receive care on holidays, Sundays                                       1­800­670­2809
  3. 3.                                       1­800­670­2809 and around catastrophic weather events when offices are likely to remain closed. Such entries are again sharp indicators of fraud. • Reporting treatment protocols that are either not compliant with best practices or established standards of care, or are not FDA approved: This is when medical records show that practitioners have used medical devices that are not approved by the FDA, or that they have employed illegitimate diagnostic or treatment protocols. A Comprehensive Fraud Control Program Is Essential Undoubtedly, health plan dollars that are to be spent on legitimate patients will not fall into the wrong hands if an effective fraud control program is in place. Professional medical review companies can help identify fraud in medical records through highly efficient programs. This helps insurers distinguish false medical claims and avoid paying them. This in turn ensures that the cost is controlled and payment made only to deserving providers. Posted by MOS Medical Record Review Company                                       1­800­670­2809