According to the Internal Revenue Service, healthcare fraud is on the rise. In 2014, there were 100 investigations into fraud initiated with prosecution recommended for 70 cases. In 2016, there were 127 cases investigated with 101 recommendations for prosecution. In addition, healthcare fraud costs tens of billions each year in financial losses. Fortunately, healthcare fraud is committed by a small number of people as most follow the rules when it comes to submitting insurance information. If you operate a healthcare clinic, there are steps you can take to be sure your clinic is not charged with healthcare fraud due to errors by your staff.
One of the most common healthcare frauds is entering false diagnoses of medical conditions into the records of the patient. This can cause issues in more ways than one. Not only does this mean the clinic bills the insurance company for treatment of conditions that do not exist, but the patient’s medical records will also be incorrect. If they change doctors or see a specialist, their treatment may suffer because their records have incorrect information. It is possible that an incorrect diagnosis could be entered accidentally by a staff member with no intent of fraud. It is critical that you impress upon your staff that extra care must be taken with medical records to insure their accuracy, not only due to billing issues that can arise, but also to protect the patient.
Medical records include a significant amount of personal and confidential information beyond health data. Patient addresses, birthdates and even social security numbers are stored with medical information, especially for insurance purposes. Theft of insurance information can lead someone who is not authorized to claim coverage under someone else’s insurance. It can also result in erroneous information being added to someone’s medical record or the creation of an entirely false record in that person’s name. This could lead to a patient having their medical insurance benefits being exhausted or information that makes them ineligible for certain types of insurance included in their health record. If your clinic stores data electronically, it is recommended that you add encryption software to protect your records from hacking. Be sure that all staff protects any confidential information by covering social security numbers while records are in the open and turning monitors so others cannot see when entering data.
There are patients who purposely commit healthcare fraud as well and it is important to train your staff how to prevent a patient from using someone else’s medical information. Always require photo identification in addition to insurance cards. Scan a copy of the patient’s license and the card into your computer system or make a photocopy for a paper file at each visit. If there is an audit of your files, you will have documentation that the patient was who they said they were. Despite all your best efforts, you could have an unscrupulous staff member or one who makes a serious error that results in charges of healthcare fraud. If this should happen, it is important that you contact a fraud defense attorney who can guide you through the legal process.
It is not just medical information that can lead to healthcare fraud. You may also find yourself in the middle of an investigation if you or your staff are not vigilant about patient prescriptions. With a growing opioid epidemic believed to have begun due to the over-prescribing of pain medications, federal and state governments are requiring more restraints when it comes to prescribing medications. Staff should ask about all drugs the patient is taking and know how to recognize an addiction. Signs may include increases in the amount of medication needed, unscheduled refill requests or frequent requests to refill.
Another way that patients may attempt to engage in healthcare fraud is by something known as “doctor shopping.” This often occurs when a patient becomes addicted to a prescription drug but can also happen when a patient is attempting to defraud a health insurance company. Patients who move from doctor to doctor may be involved in defrauding health insurance companies or they may be attempting to continue a prescription habit they may not even be aware they have. If a patient visits your clinic who has seen several doctors in the past few years, you may be dealing with a “doctor shopper.” Put plans in place so that your staff can address anyone who seems to be moving from doctor to doctor whether it is for false treatments or prescription drugs.
Dixie Somers is a freelance writer and blogger for business, home, and family niches. Dixie lives in Phoenix, Arizona, and is the proud mother of three beautiful girls and wife to a wonderful husband.