Find-A-Code Focus Newsletter

7 Fraud Red Flags You Need To Know

March 09, 2011

Every year, the Office of the Inspector General (OIG) publishes a very lenghty "work list".  This work list outlines the coding/claim areas that they will be focusing on during the year and also those areas that will soon receive attention.

Providers MUST be proactive in knowing what the OIG is looking for and then take appropriate measures to address these areas BEFORE an audit by an insurance company occurs.  The OIG calls this a baseline audit and recommends that all providers perform their own baseline audit. Baseline audits will be addressed at a later date.

When performing your own audit (whether pre-claim or post-claim), please consider the following information in a recent article in Advance for Health Information Professionals.  The article listed seven audit red flags. They are:

  1. Provider notes are exactly the same for multiple patients.
  2. Medical charting is materially changed after the date of treatment.
  3. Charting alleges treatment on an unlikely day.
  4. Charting notes are inconsistent with x-ray, lab or pharmacy data.
  5. Medical records allege same patient was in two places at the same time.
  6. Patient recollection of care is inconsistent with medical records.
  7. Medical records may reveal treatment protocols that do not comport with best practices or prevailing standards of care, or exhibit non FDA approved treatment.

To read the entire article, CLICK HERE.


Source: InstaCode Institute


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