How to Detect Fraud in
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
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
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
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