by
Barbara Kram, Editor | March 18, 2009
Red flags include the obvious such as claims on behalf of deceased patients, to more subtle address information or mismatching medical information -- telltale signs that something may be very wrong. "It could be a spike of claims, the type of claims, the types of patients, the frequency and date on which these things occur. There are a number of different schemes that indicate some kind of risk."
While Portice will not give details on the company's proprietary technology, the company's software and services define and find these patterns. In some cases, provider information is stolen and misused unknown to the doctor, such as for gaining prescription drugs under false pretenses.
"In that case the provider is innocent. But if the provider is falsifying data in records and submitting information then he is the perpetrator," Portice said, acknowledging that this is the most common scenario.
The Bush administration and now the Obama administration have both placed a priority on shifting to electronic health records. Considering the potential to use software tools for fraud monitoring by public insurers, the urgency is clear.
"Electronic records will help tremendously not only in the administration and reduction of medical errors but in the identification of potential ID theft," Portice said.
To prevent medical ID fraud, he had these suggestions for health care providers: Be careful about how you release your identification information. And review remittance statements from payors to ensure the claims and amounts are consistent and reconciled in your own practice.
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