Fraud in the Healthcare System

Posted by on Feb 23, 2014 in Best Practices, Blog, Health Care, Legal Nurse Consultant, Legal Nurse Consulting, Litigation Tools

Better Education and Technical Know-how Can Combat the High Cost of Fraud The FBI estimates that healthcare fraud costs the country an estimated $80 billion a year!  It’s the Number One factor responsible for the country’s astronomical increases in healthcare costs. Fraud defined The National Health Care Anti-Fraud Association says that healthcare fraud is “an intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual or the entity or to some other party.” Fraud and abuse can come in many forms.  It can include acts (and inaction) committed by providers as well as patients.  Providers may, for example… Bill for services not provided Duplicate submission of claim for same service, Misrepresent the service provided, and Bill for a covered service when the service provided was actually not covered Plan Members may abuse the system by… Doctor shopping Filing for reimbursement on services or medications not received or performed Falsification of information or injury Forging or selling prescription drugs, and Using transportation benefit for non-medical related business Why is healthcare today so vulnerable to fraud?  One reason is that medicine has become much more complex, and the doctor-patient relationship has changed.  For instance, a patient nowadays might be under the care of multiple providers, and each provider might not have a clear picture of the patient’s plan of care. Another reason the system is vulnerable to fraud relates to constant changes in billing and coverage.  Terms and conditions of reimbursement often change, too, and they’re highly technical and arcane.  Moreover, the urge – whether cultural or economic – for quick fixes creates opportunities for fraud. What’s being done about it? Various public and private-sector anti-fraud organizations have formed.  Through education and working with lawmakers and regulators, they’ve made progress preventing fraud and reducing its cost to the system.  The legal nurse consultant is another resource to which many fraud investigators have turned for the technical knowledge and experience it often takes to spot a fraudulent medical claim. Jordan Ilderton, RN, BSN is a Legal Nurse Consultant with MKC Medical Management.  Contact Jordan at...

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ER Documentation Review Tips

Posted by on Aug 2, 2012 in Blog, Claims Tools, ER Documentation, Litigation Tools, Medical Records

Review ER Records from Multiple Angles Reviewing emergency room documentation can be challenging.  Gathering and assimilating the appropriate information from ER reports represents a crucial step in evaluating a case, relatedness and specific injury issues. Learn your basic ER documentation and how it all fits together! Follow these tips. loans for bad credit instant decisiononline cash loan lenders A patient’s medical history can disclose pertinent details regarding his current/prior condition. Review medical authorization forms personally signed by the patient.  These can offer critical insight into the case and provide access to the patient’s past medical records without violating HIPAA regulations. Review ER records against other physician’s notes, prior surgeries/tests and EMS records, to determine whether the complaint relates to past symptoms or issues. You can learn a great deal about a patient’s medical state based on the physician’s notes.   Also be aware that new findings/complaints can develop after ER discharge and all the more reason why a close review of the initial ER record is important and follow up on the records is important. Do ordered tests match completed tests?What was specifically ordered?  Was the physician trying to rule something out or confirm a clinical finding or suspicion?  Did the physician NOT order testing, despite the injured party’s request for it? Did the injured party complete the ordered diagnostic tests? Sometimes confirmatory testing will have to be done with in a specific time parameter, so follow the order trail and request test/lab results. Review discharge instructions and note how/if/when the injured party complied. Compliance issue can greatly impact the file/case. Also remember that patient does need to take responsibility when following doctor orders....

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Case Managers and Legal Nurse Consultants Help Identify Fraud

Posted by on May 14, 2012 in Blog, Case Management, Legal Nurse Consulting, Litigation Tools

There’s a group of people who really love the U.S. health care system — the fraudsters! Like sand through your fingers, fraud can cost untold money losses for your company. Today’s smart business companies must focus on protecting their assets through proactive measures to identify insurance fraud. Hiring a Case Manager (CM) and or Legal Nurse Consultant (LNC) can help to identify both provider and claimant insurance fraud. The knowledge they provide can save your company thousands of dollars per case. We all know that false claims cost your company millions of dollars a year but providers are habitual offenders as well. The health care providers who commit these fraud schemes encompass all areas of health care, including hospitals, home health care, ambulance services, doctors, chiropractors, psychiatric hospitals, laboratories, pharmacies, and nursing homes. Violators may be prosecuted under: 18 U.S.C. 1347 Health Care Fraud. Case Managers’ and Legal Nurse Consultants’ education and experience come directly from working within the health care system and because of that they can identify many fraud indicators that an insurance adjustor might miss, whether it’s a claimant or a provider. CMs and LNCs represent powerful tools, so why would an adjuster not use all the tools available? That’s a good question but only the adjuster can answer it. Case Managers Play Critical Role In Identifying Provider Fraud This is because they actually work with the patient and some of the patient’s providers. They’re able to verify if the patient’s needs are being met through observing if the patient has the proper medication, equipment, diagnostic testing and services.  They act as your very own Private Detective, so to speak. CMs can alert you to red flags such as: Billing for services not rendered. cash loan for bad creditEasy Money Cash Advance Billing for services performed by a lesser qualified person. Misrepresenting procedures performed to obtain payment for non-covered services. Billing for a more costly service than the one actually performed. Billing each stage of a procedure as if it were a separate procedure. Legal Nurse Consultants Play Critical Role In Identifying Claimant Fraud  Legal Nurse Consultants are highly educated have state licensing as Registered Nurses. As such, they have much to offer at the claim negotiating table. Their vast medical knowledge and experience can provide an insurance adjuster with valuable insight into reducing the monetary claim demand. LNCs can alert you to red flags such as: Pre-existing conditions. Varying diagnostics results. Over utilization of services. Exaggerated symptoms. Malingering behaviors. Drug seeking behaviors. Analysis of ambiguous and subjective symptoms. Case Managers and Legal Nurse Consultants can be worth their weight in gold. Your gold! An average CM case costs approximately $1200.00 a month. An average LNC...

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Just The Facts Ma’am: The Joe Friday Approach to Reviewing Medical Records

Posted by on Feb 27, 2012 in Blog, Legal Nurse Consultant, Litigation Tools

Ladies and Gentleman, the stories you are about to hear are true, only the names have been changed to protect the innocent…  These memorable lines opened each episode of the 1950s era police series, Dragnet.  The popular crime drama chronicled the daily routine of a Los Angeles detective, Joe Friday, and his partner.  Series writer Jack Webb emphasized realism, and was a self-proclaimed stickler for details—often to the point of tedium. In the truest documentary fashion, Dragnet tracked every aspect of Sergeant Friday’s police work, step by step: from patrols and paperwork, to crime scene investigation and lab work — he questioned witnesses, suspects, and victims. The dialogue was clipped and sparse, influenced by what is known as the Hardboiled School of crime fiction.  Webb’s deadpan detective character, with notepad in hand, is now a stock character of American television and film.  Friday’s catch phrase “Just the facts Ma’am” is not only legend, it’s the sort of terse line to which more recent crime show writers of CSI, or Law & Order aspire. Examining the Medical Evidence – A Paper Trail to Truth  In many ways, the exacting attention to detail, keen observations, and objective record keeping that made for Detective Friday’s solid police work also characterizes the work of a conscientious reviewer of medical records. Often, the legal teams and insurance adjustors will ask a trusted medical provider to review the medical records of a fellow provider. They are requesting a peer review by a practicing clinician, one that reviews the original injury, treatment protocol, recorded documentation and overall treatment strategies. While all health care professionals should keep meticulous records, primary care providers must keep records beyond reproach. As the patient’s source of medical care, the significance of precise record keeping simply cannot be overestimated. Knowing the Consultant’s Professional History An experienced, well-connected Legal Nurse Consultant (LNC) will already have trusted medical providers in his or her network of medical experts. The LNC will have an established practice, and know the professionals on their list well. She has worked with them previously, and can attest to their record reviewing qualifications and history. Again, the true facts. check cash pacific Just the Facts Ma’am – Words to Win By During the medical records review, the medical provider alerts the LNC of any discrepancies or indiscretions detected in the records. The physician, chiropractor, or other licensed care provider will arm his partner with hard, objective facts that she can then use to construct a full chronological illustration of the case — from the very beginning to the present time. That chronology can reveal any missing critical steps, any unnecessary treatments or therapies in the case. Questionable record keeping and practices,...

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Best Practice – Physician Peer Review, LNC Report, or Both?

Posted by on Feb 8, 2012 in Blog, Claims Tools, Litigation Tools, Workers Compensation

It may seem redundant, or not cost effective; to utilize both a Physician Peer Review and an LNC Report. However, they both have a unique perspective. And when you combine the two, the result affords you a more complete timeline of both the events that have happened, and what may still occur with the patient. The Physician Peer Review  i have bad credit and i need a loanconsiders all casestraditional loaning process A major standard in the industry, a Physician Peer Review, or medical review, of the case can give you a pinpointed, detailed reporting of what has happened to date. It provides intricate details about specific pieces associated with the medical event and how those pieces fit directly together. More myopic in construction, the medical review yields very precise answers and insight to a medical event and subsequent treatment strategies. Simply put, consider it a very accurate snapshot in time of the patient and the event. The LNC Report  Also a major standard in the industry, the LNC takes the medical review and expands it. It provides information about peripheral factors relevant to the case as well. It considers long-term patient care and interaction, the insurance role in the completion of the case, and a review of all record keeping involved. This broader approach can easily yield inconsistencies that may otherwise go undetected. It can also yield administrative concerns that can directly affect other cases. Using a Whole Person Approach The patient involved may have a single event or episode in your facility. But the effects and ramifications of that single event can weigh heavily on the future treatment of all patients. By utilizing both reports you garner a more complete picture of the patient’s impact on the health care profession and the associated support industries. Without using both reports, you could very well end up making future patient decisions with one eye closed. Crossexamine: Do you utilize LNC reports and Physician Peer Reviews as litigation tools?  Image credit: shutterstock dot...

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Another Important Must-Win Case? Get The Edge You Need to Win

Posted by on Nov 30, 2011 in Blog, Case Management, Legal Nurse Consultant, Litigation Tools, LNC

Thanks to television courtroom dramas and the 24-hour live news cycle, we’re all familiar with expert witnesses.  Perhaps none are more dramatic than medical experts who, when they take the stand, can make or break a case.  Though these moments make for exciting TV, in actuality, no one from either side of the room relishes landing in court.  While doctors are certainly well versed in their field of medical practice, few have much practical experience in the field of law.  When you add a Legal Nurse Consultant (LNC) to your legal team, you gain an invaluable asset with specialized insights in both arenas — and, LNCs do most of their work behind the scenes—where it really counts. TOP Reasons To Add a Certified LNC To Your Legal Team  Time is Money—Save Both An LNC is both cost- and time-effective.  Whether the LNC conducts a pre-trial screening of complex medical records, or reviews medication and therapeutic treatment protocols, her dual knowledge of medical and legal procedures provides that intangible edge for your team – an edge that could mean the difference between winning and losing. LNCs act as “medical interpreters” to both distill and translate the technical issues that are critical to all phases of your case— arbitration, deposition, mediation, validating case merits, fraud detection, pre-trial preparation.  This leaves your staff free to focus on the core legal tasks and prep. Merits of the Case—Build a Solid Case  No matter how many times those outside the legal field see contracts and other legally binding instruments, it’s always prudent and recommended that an attorney review the documents before any signatures find their way to the page. Likewise, even though you may have a strong knowledge of medical terminology, treatment strategies, and medication protocols due to your prior litigation experience, there’s still a significant chance you may miss something critical to the case buried in (or missing from) the medical records. You don’t want to pay the high fees commanded by medical doctors to review the medical aspects of your case file – save your physician expert, and the fees associated with his services, for in-person testimony before the judge at trial, for expert deposition OR for a laser pointed desk review/consultation. A certified LNC can handle all aspects of case review and claim/file validation behind-the-scenes. A qualified LNC possesses a deep working knowledge of medical and associated case terminology as well as causality, case merit, and expert witness selection expertise. Bring an LNC in to review the merits of a case before using scarce and costly resources before case merit is unequivocally established.  In addition, the LNC report/work product is very different and should give a broader view of the case,...

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