Health care billing monitor system for detecting health care provider fraud

• US 6,826,536 B1
• Filed: 07/22/2000
• Issued: 11/30/2004
• Est. Priority Date: 07/22/2000
• Status: Expired due to Fees

• Current Assignee: Bert Forman
• Original Assignee: Bert Forman
• Inventors: Forman, Bert
• Primary Examiner(s): Thomas, Joseph
• Assistant Examiner(s): Bleck, Carolyn
• Application Number:
  US09/620,320
• Time in Patent Office: 1,592 Days
• Field of Search: 705/2-3, 705/4, 705/38-40, 705/42, 705/44, 705/35, 379/114, 379/114.4
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 30/20 for handling medical images, e.g. DICOM, HL7 or PACS

Abstract

A health care information management system uses a pre-existing database of medical specialty claims, such as anesthesia claims, to profile the billing behavior of medical specialist providers, such as anesthesiologists. The software helps the user to determine which of the claims submitted by the providers are within accepted guidelines and industry standards. The software identifies providers who have submitted improper false claims. This is accomplished by comparing submitted claims with a database of histories of prior claims, as well as records of time accumulated data supplied by sources originating from hospitals, physicians and societies. The software incorporates unique triggers, which highlight those claims that indicate possible fraudulent submission. The system develops a profile of a provider'"'"'s billing behavior and compares it to his peers. The software uses trigger filters to alert the insurance carrier if the provider'"'"'s billing falls outside of a predetermined norm.

Claims

1. A data processing system for detecting health care provider fraud, comprising:

a. computer processor means for processing data;

b. computer storage means for storing data on a storage medium;

c. first means for initializing the storage medium;

d. second means for processing data regarding payment claims submitted by health care providers to payers wherein said payment claim data is processed to identify and flag fraud-suspect inconsistencies and anomalies regarding payments claims submitted for payment by health care providers;

e. third means for calibrating the processed data to enable appropriate identification of the fraud suspect inconsistencies and anomalies;

f. fourth means for fraud-profiling of individual health providers based on an accumulated history of claims submitted by an individual health care provider;

said data comprising an accumulated individual provider claim history of the individual health care provider;

said fourth means further comprises means for inputting, displaying, retrieving processing, comparing, filtering and storing on the storage medium

i. data comprising an accumulated history of discrete data representing claims submitted for payment by an individual health care provider being profiled; and

ii. subjecting said data comprising said accumulated individual provider claim history to at least one profiling modifier fraud-flag data processing filter, said profiling filter identifying and fraud-flagging inconsistencies between said accumulated claim submission history of said individual provider when those data are compared to the normative health care parameters for the same medical care events and procedures derived from statistical normative data furnished by health care industry, insurance industry, and/or governmental health care insurance payer information data bases.

2. A data processing system for detecting health care provider fraud, comprising:

a. computer processor means for processing data;

b. computer storage means for storing data on a storage medium;

c. first means for initializing the storage medium,

d. second means for processing data regarding payment claims submitted by health care providers to payers wherein said payment claim data is processed to identify and flag fraud-suspect inconsistencies and anomalies regarding payments claims submitted for payment by health care providers;

e. third means for calibrating the processed data to enable appropriate identification of the fraud-suspect inconsistencies and anomalies;

fourth means for fraud-profiling of individual health providers based on an accumulated history of claims submitted by an individual health care provider;

further wherein;

a. said first means further comprises means for inputting, displaying, retrieving processing, comparing, filtering and storing on the storage medium individual health care provider payment claim data; and

b. said second means further comprises means for inputting, displaying, retrieving processing, comparing, filtering and storing on the storage medium data comprising at least one fraud-flag data processing filter to identify and flag fraud-suspect inconsistencies and anomalies regarding payment claims submitted for payment by health care providers; and

c. said third means further comprises means for inputting, displaying, retrieving processing, comparing, filtering and storing on the storage medium calibrating data for said at least one fraud-flag data processing filter, said calibrating data comprising

i. reference data regarding health care procedure billing parameters, said billing parameters data being furnished from health care industry, insurance industry, and/or governmental health care insurance payer information data bases; and

d. said fourth means further comprises means for inputting, displaying, retrieving processing, comparing, filtering and storing on the storage medium

i. data comprising an accumulated history of discrete data representing claims submitted for payment by an individual health care provider being profiled; and

ii. subjecting said data comprising said accumulated individual provider claim history to at least one profiling modifier fraud-flag data processing filter, said profiling filter identifying and fraud-flagging inconsistencies between said accumulated claim submission history of said individual provider when those data are compared to the normative health care parameters for the same medical care events and procedures derived from statistical normative data furnished by health care industry, insurance industry, and/or governmental health care insurance payer information data bases.

3. A data processing system as in claim 2, wherein said second means further comprises:

a. at least one fraud-flag data processing filter further comprising a time-difference flag generated in response to a predetermined calibration threshold when the time duration reported on a payment claim by an individual health care provider for a patient care event is compared to an independently recorded measurement of the same time duration as reported by a hospital or other health care provider; and

b. at least one fraud-flag data processing filter further comprising an unbundling flag comprised of comparing the procedures reported by a health care provider as performed on a single patient in a single episode of medical care with an over-all treatment code covering the same health care rendition to determine whether the health care provider has improperly reported and claimed payment for unbundled individual component parts of medical care rendered to a patient rather than properly reporting and claiming payment for a single, and thus bundled, event of medical care rendition;

c. at least one fraud-flag data processing filter further comprising a financial amount threshold flag wherein the monetary amount of a given health care provider claim for payment is compared to a predetermined financial threshold so as to flag those claims that are above the financial threshold;

d. at least one fraud-flag data processing filter further comprising an upcoding flag for comparing the procedures reported by a health care provider as having been performed on a single patient in a single episode of medical care with the reports of the same procedure independently furnished by other health care providers or surgical theater institutions to determine if the procedure reported by the individual claimant health care provider whose claim is under review is properly the same as or improperly different from the procedure independently reported by other health care providers who rendered care in the same medical care rendition event to the same patient at the same time and place;

e. at least one fraud-flag data processing filter further comprising an outpatient non-JCAH facility data processing filter to compare the site of health care rendition claimed by a provider in a payment claim with a list of JCAH accredited health care facilities, so as to flag those sites in which health care being claimed for payment was performed outside a JCAH accredited facility;

f. at least one fraud-flag data processing filter further comprising a multiple-provider-identity flag based on comparing the individual information identifying particular to health care providers with payment claims submitted by other health care providers having different addresses and different business entity names to determine if the same health care provider as identified by a never-varying Medicare provider number has submitted claims for payment for health care provided to patients under an improperly and superficial multiplicity of names and/or addresses purporting, within said superficial multiplicity to simultaneously be both a participant medical care provider and a non-participant provider under a particular contractual scheme of reimbursement, fraudulently appearing to the payer to entitlement to differing reimbursement rates by virtue of the improper multiplicity of claimed health care provider identities.

4. A data processing system as in claim 3, wherein said second means further comprises;

a. at least one fraud-flag data processing filter further comprising a pain management flag generated in response to data identified as representing the unbundling of pain management medical care events for which payment is claimed by individual health care providers; and

b. at least one fraud-flag data processing filter further comprising a No-Fault Insurance Claim flag generated in response to data identified as representing the rendition of medical care events for a plurality of patients under claim for reimbursement under a no-fault scheme of automobile insurance wherein the same diagnosis has been reported by and claimed for payment by a given health care provider for more than a predetermined number of patients in a predetermined time period; and

c. at least one fraud-flag data processing filter further comprising a Disability Insurance Claim flag generated in response to data identified as representing the rendition of medical care events for a plurality of patients under claim for reimbursement under a disability scheme of insurance wherein the same diagnosis has been reported by and claimed for payment by a given health care provider for more than a predetermined number of patients in a pre-determined time period.

5. A data processing system as in claim 4, wherein said health care provider fraud detection is directed to the field of medical pain management, and wherein:

a. said unbundling modifier fraud-flag data processing filter further comprises filtering data for and flagging inconsistencies between accumulated claim submission history of said individual pain management health care provider when those data are compared to the normative health care parameters for the same pain management health care events and procedures derived from statistical normative data furnished by health care industry, insurance industry, and/or governmental health care insurance payer information data bases; and

wherein further said normative health care parameters for pain management health care events comprises a data filter for whether or not the pain management provider reported, in a plurality and pattern of claims for payment, at least one of;

i. X-Rays of the spine;

ii. fluoroscopy of the spine;

iii. local anesthesia;

iv. insertion of needle;

v. injection of steroid drugs; and

vi. sedation of the patient;

wherein further, said pain management provider will be individually fraud-profiled by comparing aggregated multiple patient claim data from claims for payment for each above-enumerated pain management steps submitted by an individual pain management provider compared to the global, bundled treatment codes for at least one of;

i. trigger point injections;

ii. lumbar nerve block;

iii. myelogram;

iv. paravertebral nerve block; and

v. lumbar epidural.

6. A data processing system as in claim 5, wherein resulting flagged fraud detection information is displayed to a user.

7. A data processing system as in claim 6, wherein resulting flagged fraud detection information is displayed visually and in printed form.

8. A data processing system as in claim 6, wherein said system is useable remotely by having means for inputting at a source computer of payment claim data;

means for remote users to transmit said remote input claim data to a central processing computer located elsewhere by data communications means and means for returning the processed data, with flags fraud having been generated to said remote users said processed data being in visually displayable form, printable form, computer storable and computer readable form.

9. A data processing system as in claim 4, wherein resulting flagged fraud detection information is displayed to a user.

10. A data processing system as in claim 8, wherein resulting flagged fraud detection information is displayed visually and in printed form.

11. A data processing system as in claim 9, wherein said system is useable remotely by having means for inputting at a source computer of payment claim data;

means for remote users to transmit said remote input claim data to a central processing computer located elsewhere by data communications means and means for returning the processed data, with flags fraud having been generated to said remote users said processed data being in visually displayable form, printable form, computer storable and computer readable form.

12. A data processing system as in claim 2, wherein said health care provider fraud detection is directed to the field of anesthesiology, and wherein:

a. said time-difference flag comprises a comparison of the number of standard anesthesiology 15-minute time units, converted into absolute minutes by multiplying units ×

15, with the absolute number of minutes reported by a surgical theater facility for the same procedure on the same patient within the same event-day; and

wherein

i. said calibration of said time-difference flag comprises a pre-determined selected number of standard deviations of absolute minutes of time difference report as between the anesthesiologist and the surgical theater facility wherein 1 standard deviation comprises about 20 minutes;

two standard deviations comprises about 45 minutes;

three standard deviations comprises about 50 minutes; and

four standard deviations comprises about 60 minutes;

b. said profiling modifier fraud-flag data processing filter further comprises filtering data for and flagging inconsistencies between accumulated claim submission history of said individual anesthesiologist provider when those data are compared to the normative health care parameters for the same anesthesiologist medical care events and procedures derived from statistical normative data furnished by health care industry, insurance industry, and/or governmental health care insurance payer information data bases; and

wherein further said normative health care parameters for anesthesiologist medical care events comprises a data filter for whether or not the anesthesiologist reported, in a plurality and pattern of claims for payment, at least one of;

i. insertion of an arterial line;

ii. use of a central venous pressure monitor;

iii. utilization of controlled hypertension;

iv. the coding or declaration of an emergency;

v. the use or recording of an American Society of Anesthesiologists (ASA) evaluation upgrade; and

,

vi. the use or coding by an anesthesiologist patient risk value in the range P3 through P5 inclusive where risk ratings comprise P1 representing a normal patient;

P2 representing a patient with mild systemic disease;

P3 representing a patient with severe systemic disease;

P4 representing a patient in constant threat of death; and

P5 representing a moribund patient not expected to survive 24 hours; and

,

c. a financial amount threshold flag is calibrated to filter anesthesiologist claims for payment for dollar amounts that exceed a predetermined amount of the dollar amount billed by a surgeon for the same procedure upon the same patient at the same place on the same event-day.