Unearthing fraud, mistakes and other claims errors takes more than an expert detective…even one as skilled as Charles Piper.  That’s because no matter how experienced or well-trained, a non-healthcare professional alone is not enough to defend against a bad claim.

Healthcare fraud is a big problem, costing tens of billions of  dollars a year and impacting all of us.  That’s compounded by the thousands of bad claims that result from mistaken diagnoses, misinterpretation of medical records or other deliberate and accidental oversights.

Back in 2013, a private investigator and consultant by the name of Charles Piper wrote one of the best summaries I’ve ever seen of the most common health care provider fraud schemes. For example, Piper explained how billing for services not rendered, billing for a non-covered service as a covered service and misrepresenting dates of service topped his list. He also described how misrepresenting locations of services and providers of services, waiving of deductibles or co-payments, incorrect reporting of diagnoses or procedures (includes unbundling) and overutilization of services robbed the system.  In conclusion, Piper cited old-fashioned corruption (e.g., kickbacks and bribery) and false or unnecessary issuance of prescription drugs as examples of provider fraud.

Here are some of things I look for when I’m reviewing complex cases:

For starters, medical records are often incomplete. Office notes, hospital records and even test results might be missing, leaving critical gaps in treatment. Yet, in order to have a clear picture of the claimant, the injury, the medical treatment and the diagnosis, we must have all of the records.

The problem

Red flags always go up for anybody trained to assess injury claims when we discover the records are incomplete. That’s because missing records may contain valuable information regarding the injury.

They often hold the key to the relationship, if any, between the mechanism of injury and the alleged injuries. Records, which can define pre-existing illnesses and injuries or even date the injury to a much earlier or later time, may be purposefully omitted.  Alarms should go off for anybody involved with claims that have identifiable pre-existing orthopedic or neurological conditions. Why? Because these conditions often set the baseline for  specific conditions.  Pre-existing pathology very often impacts treatment protocols/choices, rehab and/or recovery, as well as making it difficult to separate out old-versus-new symptomology.

Unfortunately, when records are submitted, they are rarely complete.

Best practices

There are several ways to determine whether you have the full file.

  1. Pay close attention to the page numbers. When page 22 skips to page 45, for instance, this is frequently the first clue that documents are missing. Look for any gaps and ask for the missing records.
  2. Look at the dates of service on the billing and compare the dates with the records received. An office note may sometimes refer to an earlier appointment, which is another way to check for completeness. If you don’t have records from that earlier appointment, something is missing from the file.
  3. Notice the physician “ordering” any diagnostic tests and make sure there are medical records documenting why the test was warranted. Many time those physicians are left out of the record.
  4. Date lapses in the records can also indicate possible missing records.

Bottom line

The reviewer must have a complete set of records to accurately assess the reported injuries, the mechanism of injury, any pre-existing pathology and what the relationship may be between the alleged injuries and the event.

Rendering an opinion without full assessment of the file can lead to a costly acceptance of claims, which possibly could have been avoided if the records had simply been complete. Make sure you have the full file.

KARI