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The MedMetrics blog provides comments and insights regarding the world of Workers’ Compensation, principally, issues that are medically-related. The blog offers viewpoints regarding issues affecting the industry written by persons who have long experience in the industry. Our intent is to offer additional fabric, perspective, and hopefully, inspiration to our readers.

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Tuesday, August 13, 2019

Workers' Compensation Medical Provider Fraud A Sum of Subtle Maneuvers

by Karen Wolfe
That medical providers might commit fraud is disconcerting. Exemplary performance in life and work is generally expected. While doctors’ performance is evaluated and scored regarding treatment processes and outcomes, actual fraud is rarely considered. We assume all providers in an approved network are honest, dedicated medical professionals, but that is not always true. Some use subtle maneuvers to disguise their excess profitability.
Some providers, primarily doctors, deliberately mislead employers and payers by obfuscating the data. They game the system with subtle billing maneuvers and other evasive tactics that are not easily recognized.

Gaming the system is easy
Workers’ Compensation data is known to be of poor quality, especially provider demographic records that are overwhelmingly inaccurate and incomplete. Duplicate records abound thereby creating the opportunity to further complicate identities, affiliations, and actions. Untangling data deception is challenging and time-consuming at best.

Fight medical provider fraud
The best way to fight medical provider fraud in Workers’ Compensation is to prevent it. If the data were of good quality, the opportunity for fraud would be nearly eliminated. Complete, accurate, and non-duplicative provider record data would prevent medical fraud because analyzing quality data is easy. Analyzing bad data is complicated and elusive. Requiring medical providers, possibly on pain of non-payment, to submit bills with accurate and consistent demographic data is the first critical step. Maintaining that accuracy in the payer system is equally imperative. But that is not happening.

Cut to the chase
An immediate way to fight medical provider fraud, after preventing fraud by guaranteeing pristine medical provider record data, is to engage the assistance of experienced Workers’ Compensation medical data analytics professionals. Based on knowledgeable analysis, subtle data maneuvers are uncovered. The doctors that should be avoided are identified as well as the reasons for avoiding them. Remove, avoid, or transform fraudulent doctors in the network to save money, improve outcomes, and elevate the entire network.

Of course, analyzing medical providers on a broader scale is even better. Performance based on medical costs, treatment patterns, prescription practices, return to work, medical and disability outcomes along with accurate billing practices presents a more comprehensive portrait. Fraudulent providers find multiple ways to cloak their activities for greater profit.

Transform fraudulent doctors
Publish the documented fraudulent behavior to dissuade the perpetrators of further attempts to muddy the data water. The Hawthorne Effect[1] applies, whereby the behavior of subjects improves based on the knowledge they are being observed. Publish documented data analytics to inform providers they are being observed and evaluated. Public embarrassment is a strong deterrent. Distributing graphic portrayals of the perpetrators’ behavior will inform and transform even the most recalcitrant.

More dramatic outcomes are not infrequent when fraudulent providers are “outed” through analytics. Litigation is sometimes a successful result because analytics documents and proves the errant behavior. Fundamentally, medical provider fraud is costly, but it can be addressed and eliminated.

Karen Wolfe, BSN, MA, MBA is the founder and President of MedMetrics®, LLC, a Workers’ Compensation analytics-Informed medical management and technical services company. MedMetrics analyzes the data and offers online insights that link analytics to operations, thereby making them actionable and measurable. MedMetrics also uncovers medical fraud. Contact: karenwolfe@medmetrics.org

[1] The Hawthorne Effect is the alteration of behavior by the subjects of a study due to their awareness of being observed. www.dictionary.com