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Finding Shark Teeth

Finding Shark Teeth Review It

Recognizing Fraudulent Billing Patterns

Posted on 06/09/09 at 11:10PM

On my desk is a small collection of shark teeth I’ve collected from my favorite beach. They not only serve as a reminder of a treasured vacation pastime, but also as a symbol of the work I do as a registered nurse clinical analyst, reviewing claims and medical records to identify billing errors and fraud. Like hunting for shark teeth, identifying fraudulent billing patterns is a matter of not only knowing where to look, but what precisely to look for.

Shark teeth are not usually found lying in plain sight on top of the sand; they are partially buried and vary in size, shape and color. Just as the teeth differ in appearance, health care fraud can be concealed in many forms, including upcoding by providers, submittal of false claims by organized crime rings and medical identity theft. False reporting of medical services to receive monetary or other benefits is a rapidly growing and constantly fluctuating crime. Perpetrators of medical fraud are typically quick to change billing schemes and locations, always trying to stay one step ahead of investigators. They attempt to make their claims blend in with those of honest providers in order to avoid edits and audits.

As teeth on the beach are evidence of sharks in the water, suspect claims are evidence of fraudulent billers, actively seeking easy prey. Inadequate fraud control is like blood in the water, attracting both the unscrupulous provider and the hardened criminal. An effective fraud control program capable of identifying criminal practices must include human review of all suspect claims, since even the best computer programs are unable to match the pattern recognition capabilities of the human brain. Claims processors can be trained and software can be programmed to identify and flag certain obvious types of billing inconsistencies. But with billions of dollars lost to fraud every year, those methods are not enough. It takes a clinical expert to find fraud; one who is trained to scrutinize claims and medical records for anything that seems out of place. Recognizing fraudulent billing patterns requires looking beyond the obvious to find the anomalous. Expert review of claims prior to payment creates significant savings as less obvious fraud and errors are identified and incorrect payment is prevented. There are indeed greater costs associated with paying a clinical expert to review claims, but those costs are mitigated through greater claims review efficiency and payment accuracy. Clinicians know what is typically included in surgeries and procedures, the usual dosage of medications for different conditions, what supplies are necessary, the types of services performed by different provider specialties and how often particular services should be carried out. They can look at clinical notes and decipher the abbreviations and handwriting, applying years of clinical experience and training to the review process.

With an effective clinical review program in place, suspect patterns can be identified with greater efficiency and accuracy. Just like recognizing a shark tooth among shells in the sand, abusive schemes can be removed from the sea of claims and acted on before payment is sent to a potentially fraudulent biller, preventing a feeding frenzy on private and public health care dollars.


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