Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Medical Errors and Profilers

Why have a discussion on medical errors in a healthcare fraud audit and detection guidebook? Medical errors cost the market a significant amount of money. Evidence can look like a medical error when, in fact, it involves fraud. Medical errors fund waste and abuse activity. In addition, the process of auditing and detection applies. Often we can learn lessons from medical error issues that can be applied in the fraud environment. They provide a further understanding of the concept of normal versus not normal. Applying a medical profiler entails the process of inspecting clinical behavioral characteristics, descriptors, and traits of data elements, including the fees associated with those clinical services noted during a series of referential comparisons. Referential analysis is the comparison of the specified clinical data element to a specified context within the applicable parties of the P-HCC.

To illustrate the application, we return to a paragraph that appeared in Chapter 21’s discussion of narrative discourse analysis:

HPI: Jane is a 24-year-old white female who fell two mornings ago and sustained an inversion injury to the left ankle. She was seen in the ER, where the ankle was found to be dislocated and fractured. The ankle was apparently relocated. The films were apparently reviewed today by an orthopedist. Jane was informed that she would need surgery for the ankle. This is scheduled for tomorrow. However, she has had pain today, uncontrolled ...