9 Red Flags Signifying Healthcare Fraud & Abuse

by | Published on Sep 28, 2020 | Medical Record Review

Medical chart review and review of claims are significant processes with regard to effective health insurance fraud control programs. These help to identify suspicious medical claims and prevent payment to fraudsters. When a payer is alerted to the possibility of fraud, the medical records may be more closely examined. Professional reviewers at an experienced medical review company are trained to spot such red flags for abuse and fraud in a patient’s medical records.

Here are some of the most common signs of fraud and abuse you may find in a medical record or medical claim.

  • Lack of clarity regarding unusual occurrences: When unusual occurrences are inadequately described or not mentioned at all, it could be a sign that the healthcare provider or facility is trying to hide something.
  • Change in medical charting after the date of service: Providers may get nervous when there is a legal challenge or alleged medical malpractice, and attempt to make changes in the medical chart. This is usually done in an effort to modify the records in favor of the provider. However, attorneys may have the copies of the original medical records, and any change made could prove highly damaging to the healthcare provider.
  • Multiple patients have the same provider notes: It is only natural that the medical consultations for different patients will be different. The same documentation made for multiple patients sends a red signal to the medical record reviewer.
  • The medical record documentation is not consistent with lab results, X-ray or pharmacy data: In this case, claim forms are submitted to government or private insurers for medical services and care that were not provided at all, or for unnecessary medical services.
  • The medical chart shows treatment provided on an unlikely day: Routine medical treatment is not usually provided on holidays, Sundays, or on days following an emergency or a disastrous weather event such as a major hurricane. So, if the medical record shows such documentation, it could be a sign of fraud.
  • The patient does not remember a documented service being provided: When the patient’s statement regarding the care provided is inconsistent with the medical records, it is a suspicious sign.
  • Misrepresenting the dates of service, locations of service, and providers of service: Each office visit is considered a separate billable service, and fraudulent providers may report that they visited or treated the same patient on two separate days, and not on a single day. Seasoned medical record reviewers would ensure that the patient’s medical file documentation is consistent with the dates of service listed on the claim forms. Similarly, healthcare fraud also involves misrepresenting the locations and providers of healthcare services.
  • Treatment protocols that don’t comply with prevalent standards of care or best practices: Documentation regarding healthcare services that are not compliant with prevailing standards of care may be a sign of fraud. Providers may utilize diagnostic or treatment protocols that are not approved by the FDA.
  • Waiving out-of-expenses for patients: Typically, insurers do not allow healthcare providers and facilities to waive patient’s deductibles or co-payments. However, some providers waive these and then submit other false claims to insurers to make up the dollar difference. Such providers have the confidence to do so because they think that patients are unlikely to complain that their copayments or deductibles have been waived.

Healthcare fraud and abuse is a federal crime and negatively impacts Americans on the whole. It increases healthcare costs phenomenally, and therefore needs to be effectively controlled. Timely prevention and identification of healthcare fraud will help save millions of dollars that can be better utilized in providing care for legitimate patients. An effective fraud and abuse control program should focus on red flags in the medical record, typically identified during a medical chart review, that may signify some fraudulent activity or patient abuse.

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