Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Service, Medical, and Financial Errors

Once the compromised patient population has been identified, risk assessments may be analyzed further within the claims data. The ICD coding system may be used to identify, through the claim data, patients who may be at risk for additional complications because of the false claim activity. For example, within the data, one may trend the number of ER admissions that occurred after the treatment or visit by Dr. Traveler. The diagnosis coding system has codes for complications. Patients may be profiled for certain types of complications that, again, occurred after a claim visit from Dr. Traveler. If the audit or investigation noted that Dr. Traveler fabricated records, damages should be considered for the amount of resources that would be required to notify the patients and the time to address the correction of fabricated information within their medical records.