Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Analysis Considerations with Electronic Records

In the electronic world, when records are requested, they maybe provided in electronic format or a hardcopy version of the electronic file. The user needs to be prepared for both scenarios. If it is an electronic production, one file may contain what is referred to as a “header” file. Exhibit 21.13 shows a sample header file.

Exhibit 21.13 Sample Electronic Medical Record Header File

ADMISSION RECORD

Advanced Directive, Discharge, Date, Time, PT, AcctNo, FC, STARM, BD,

ATTENDINGPHYSICIAN,,PHYSICIANNED, RECNO, DateofAdm,

TIME, BYMEDSVC, TYPE, CAT, SOURCE, RELIGION /CHURCH,

SEX, MarSt, RACE, MEDIA, INIT, LastName, First Name, MI,

MaidenName, PrevAdmDate, UnderWhatName, STREETADDRESS,

CITY, STATE, ZIP, COUNTY, PHONENO, DateofBirth,

AGE, PLACEOFBIRTH, OCCUPATION, ALLERGIES, SOC SECNO,

EMPLOYER, STREETADDRESS, CITY, STATE, ZIP, PHONENO,

NEARESTRELATIVE, RELATIONSHIP, STREETADDRESS,

CITY, STATE, ZIP, PHONENO, EMERGENCYCONTACTNAME, RELATIONSHIP,

STREETADDRESS, CITY, STATE, ZIP, PHONENO, GUARANTORNAME,

RELATIONSHIP,STREETADDRESS, CITY, STATE, ZIP, GUARANTOREMPLOYER,

STREETADDRESS,CITY, STATE, ZIP, GUARANTOR, PHONENO,

PROVISIONALDIAGNOSIS, GUARANTOR, EMPLOYERPHONENO,

GUARANTOR, SOCSEC, ACCIDENT, DATE, EMPLOYERATTIMEOF ACCIDENT,

PRIONSINSTITUTIONLAST60DAYS, FROM, TO, PRIMARYCARRIER

SUBSCRIBERS NAME,, RELATN,GROUPPOLICYNO,SECONDARYCARRIER

SUBSCRIBERSNAME, RELATNGROUP, POLICY NOADDITIONALCARRIER

SUBSCRIBERSNAME, ...