Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

The Transparency Healthcare Continuum (T-HCC)

T-HCC Application

The transparency issues in the case of Dr. Traveler initially involved third party relationships. The first is the third party billing company. The professional claim form referenced as the Centers for Medicare and Medicaid Services (CMS)-1500 does not have a field to document the use of a billing agent. The claim form now requires a professional to register and obtain a National Provider Identifier (NPI) number. Any professionals providing services need to identify the procedure code adjacent to their NPI number. The market does not have a mandate for billing agents to register with any type of unique identifier. The vulnerability with claims processing is that a claim does not differentiate as to who submitted the form. This is the same issue with the collection agency that was paid to take assignment of unpaid claims.

Accuracy and quality of information will be impacted, as it is not known exactly which patients collectively received partial treatment from the provider. Once a pattern has been identified, a methodology to extrapolate damages across a claim population can be discerned. It would be difficult to literally “audit” and interview every patient encounter. Risk remains as to identifying issues or impact among every patient Dr. Traveler encountered, whether by person or through the use of their identity. Exhibit 7.1 highlights the general framework for the transparency audit continuum.

Exhibit 7.1 Transparency ...