Question

1) what kinds of discrepancies you would look for in medical records. Fraud has occurred in many medical billing cases.

2) As an investigator/auditor, what would you look for to detect any fraud?

Two things that we should keep in mind:

Concealment is generally accomplished by manipulating documentary evidence, such as purchase invoices, sales invoices, credit memos, deposit slips, checks, receiving reports, bills of lading, leases, titles, sales receipts, money orders, cashier's checks, or insurance policies.

From the time documentary evidence is received, its chain of custody must be maintained in order for it to be accepted by the courts. Contesting attorneys will make every attempt to introduce the possibility that the document has been altered or tampered with.

Answer 1

Answer

1.

15 types of medical billing fraud:

1. Upcoding: Typically submitting a claim for a service more severe than the actual service provided. For example, submitting a claim for a broken ankle, when the patient was only treated for a sprained ankle.
2. Cloning: Using an EHR system to automatically generate a more detailed patient observation profile by copying from another patient’s file with similar symptoms to appear as if a more thorough examination was done.
3. Phantom Billing: Billing for services never performed. This also affects healthcare costs in the millions of dollars invested in tracking and prevention.
4. Inflated Hospital Bills: Gross overcharges for procedures and/or on equipment used on medical bills. For example, $1,500 surgical screws or $500 Tylenol pills.
5. Service Unbundling or Fragmentation: Billing for multiple procedures separately, that should have been billed together in a bundle in order to forgo the bundled rate and increase profit.
6. Self-Referrals: When a provider refers themselves or a partner provider to perform a service, usually for a financial incentive.
7. Repeat Billing: Billing twice for the same procedure, supplies or medications.
8. Length of Stay: Charges for days not in the provider facility. Most hospitals will charge for the day you arrived, but not for the day you left.
9. Correct charge for type of room: For example, if you were in a shared room, make sure you’re not being charged for a private one.
10. Time in OR: Some hospitals charge based on an “average” time needed to perform an operation instead of the actual operation time.
11. Keystroke Mistake: Entering incorrect codes, resulting in significant overcharges or in some cases an undercharge.
12. Cancelled Service: Occasionally a medication, procedure or service that was prearranged and then canceled later but is still charged.
13. No Medical Value: Claims submitted for payment for poor service that resulted in a decline in patient’s health.
14. Standard of Care: Billing for services in which the provider failed to meet quality standards of care and provide preventative actions to safeguard patient’s health.
15. Unnecessary Treatment: When a provider performs unnecessary tests in order to bill for them.

2.

In fraud detection process concealment investigation methods comes after theft investigation method. Concealment is generally accomplished by manipulating documentary evidence, for instance manipulating the invoices like purchase invoices, sales invoices, credit memos, deposit slips, checks, receiving reports, bills of lading, leases, titles, sales reports, money orders, cashier check, or insurance policies. Also deleting or modifying records in corporate database is also falls under the electronic fraudulent activities.