Medical Fraud in Workers Comp: You Might be Part of the Problem

 

Doctors and other providers who defraud the system for their own financial benefit are few, amounting to less than 4 percent. Yet, these few account for millions of dollars spent unnecessarily and without improved outcomes. Moreover, you could be helping these doctors defraud the system.

 

 

Fraudulent providers use tactics such as increasing the frequency and duration of medical services, billing at the highest levels regardless of state fee schedules, and billing repeatedly hoping to generate duplicate payments. Even more subversive are those who add multiple diagnoses to their exaggerated billing to avoid exposure by bill review systems. Such perpetrators also shrewdly submit bills using slightly altered names and addresses so their excesses are not easily noticed by electronic systems.

 

 

 

Modifying names and addresses is an easy and effective way to obfuscate data. Computer systems are literal, meaning they accept the data as it is. Consequently, adding a comma, reversing first and last names as they appear in one field, and adding or omitting a suite number, and abbreviating are all common ways to cause the system to create multiple records. Each iteration of the information is treated as unique by most computer systems so each becomes a separate record representing the same person or entity. While providers are sometimes dedicated perpetrators of these data deceptions, payers often contribute to the problem.

 

 

Data quality in the provider demographic record in a computer system is critical to analyzing provider performance. How can individual provider performance be evaluated using analytics when multiple records representing the same person are present in the data? How can individual providers be identified when several hide behind the same TaxID number? Some providers use different names for the same office location or claim different specialties. Differentiating the good and bad is challenging.

 

 

Accurate data entry is critical to data quality, yet little attention is paid to this basic operational process. Good and bad doctors, as well as payers, are all guilty. A policy requiring names and addresses be pulled from a drop-down list of providers would prevent creating multiple entries caused by name reversals, misspellings, and key entry errors. This is basic software design. For those unable to create a hard-coded list from which the data entry person can select, a copy and paste policy should be established and enforced.

 

 

Manually typing information for each bill guarantees errors, record duplication, and confusion. Aggressive process management will significantly reduce the data entry problem.

 

 

Developing software interpretive rules to automatically correct and combine multiple records is fraught with uncertainties. For instance, a software rule might be written to interpret name reversals by looking for a comma indicating the last name is first. However, a comma is often not present, so even more confusion is created. Commas and periods, present or not, in names and address are a common issue of data quality and impossible to correct programmatically. It is a people problem.

 

 

Still, the best way to resolve the problem, whether it results from provider billing practices or data entry at the payer level, is to require unique provider identifiers such as NPI or state license numbers. NPI (National Provider Identifier) is a system required by CMS (Centers for Medicare and Medicaid Services). Individual providers must have an NPI number to be reimbursed by Medicare. Workers compensation payers should require the number on bills, a simple way to clarify provider identity. Of course, the same data entry rules must apply — either choose providers from drop down lists displaying NPI numbers or use the copy paste method to avoid inaccurate NPI number entry.

 

 

Most medical providers currently have NPI numbers because they want to be reimbursed by CMS for non-workers comp services. NPI numbers in the bill and in payers computer systems would eliminate the disguise offered by deliberate or unintended data duplication.

 

 

Fighting medical fraud is more than challenging. But it is not only providers who contribute to the problem. Clean and complete provider records where the data are entered exactly the same way for every bill received from a provider will go a long way to correcting the problem. Duplicate records would be avoided and individual performance more accurately and fairly analyzed.

 

 

Evaluating provider performance and rating providers analytically depends on correct individual identification. Multiple records in the data for the same provider generated by sloppy data entry practices simply perpetuate and exaggerate the problem.