Medical Records

The bedrock of medical care is what is documented in the medical record. It is all to easy to create a templated medical history and physical that can support a perfectly documented fraud

Claims

The main focus of fraud investigations are the diagnoses and procedures captured on claims forms. Outliers from well established payment rules and patterns of coding are identified for further investigation.

Entrepreneurial Medicine

At 18 percent of the Gross Domestic Product health care is filled with opportunities to profit. A study published in the Journal of the American Medical Association (JAMA) by researchers from health insurance provider Humana Inc. and the University of Pittsburgh School of Medicine links the waste to six areas of the health care system identified by the Institute of Medicine: failure of care delivery; failure of care coordination; over-treatment or low-value care; pricing failure; fraud and abuse, and administrative complexity.

Office-based procedures. A number of medical practices are adding tests and services that exceed the training and certification of the professionals. Examples include, Endovenous Laser Vein Therapy, Botox Therapy, Collagen Injections, Carotid Doppler, Doppler Plethysmography, and many others. In the absence of formal training, the performance and interpretation of these procedures may be sub-standard and should not be reimbursed.

 Low value Medical Services have been identified as a source of wasteful spending. The American Board of Internal Medicine has worked in collaboration with a large number of specialty societies to identify such procedures and have posted information for physicians and patients on their website; Choosing Wisely. Clinicians who order these procedures routinely should be audited more closely.

For Profit Hospitals: Can for-profit hospitals serve the interests of the community? Are not-for profit hospitals becoming more like profit hospitals? Here is the latest round in the discussion. Some useful background is here.