You Might be Helping Doctors Defraud the System

Medical fraud in Workers’ Comp comes in many forms. Determined abuse of the system, perpetrated by the most callous of providers is the most destructive form. Fraudulent doctors and other providers know the system and how to manipulate it to their financial benefit.

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 to generate duplicate payments. Even more subversive are those who add multiple diagnoses so their exaggerated billing to avoid exposure by bill review systems. Such perpetrators also shrewdly submit bills using slightly altered names and addresses so their maneuverings 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, are all common ways to cause multiple records. Each iteration of the information is treated as unique by the computer system so that each becomes a separate record representing the same person or entity. While providers are perpetrators of these data deceptions, payers often contribute to the problem.

Data quality is a people problem
Data quality in provider records is critical to evaluating provider performance. How can individual provider performance be evaluated when multiple records representing the same person are present in the data? How can individual providers be identified when several hide under the same TaxID number? How can we differentiate the good and the bad from the ugly?

Accurate data entry is critical to data quality, yet little attention is paid to the process. A policy requiring names and addresses be pulled from a drop-down list of provider records would prevent creating multiple entries caused by misspellings and similar 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. Manually typing the information for each bill guarantees error, record duplication, and confusion. Process management is needed to resolve the data entry problem.

Developing software interpretive rules to correct and combine multiple records is fraught with uncertainties. For instance, a software rule could be written to interpret name reversals by looking for a comma indicating the last name is first. However, the 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 very difficult to correct programmatically. It’s a people problem.

Unique identifier
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, as well.

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 would eliminate the disguise offered by deliberate or unintended data duplication and confusion.

Fighting medical fraud
Fighting medical fraud is frustrating and elusive. But it isn’t 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.

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.

Learn more about Provider Performance management.