by Cindy Gallee, JD, RHIA, CHC
It’s been called the most sinister, the most egregious, the worst kind of health care fraud – providers performing medically unnecessary procedures. When this type of fraud makes the headlines, it is indeed sensational.
“Doctor who gave chemo to healthy patients faces sentencing;” 1
“Doctor who ordered unnecessary heart surgery and risky tests jailed for 20 years;” 2
“Michigan doctor gets nearly 20 years for harmful and unnecessary spinal surgeries.”3
Unnecessary procedures not only cost Medicare or other insurance programs money, they can also cause significant harm to patients. The key in healthcare fraud detection is to find these cases of fraud before patients are injured.
Most often, the providers making these headlines are performing procedures in numbers far more frequent than compared to their peers. Using analytics, a health care plan can isolate those procedures that are most commonly performed unnecessarily. The following chart shows ten such procedures that have the possibility of being overused, according to a recent research study.4
| Procedure | CPT/HCPCS Code |
| Transesophageal echocardiography | 93312 – 93318 |
| Computed tomography pulmonary angiography | 71275 |
| Computed tomography in patient with respiratory symptoms | 71275 with respiratory diagnosis |
| Carotid artery ultrasonography and stenting | 37215 – 37217 |
| Aggressive management of prostate cancer (prostatectomy) | 55801 – 55845 |
| Supplemental oxygen for COPD | 4030F with COPD diagnosis |
| Surgery for meniscal cartilage tears | 29880 – 29881 |
| Nutritional support in medical inpatients | B4164 – B5200 on inpatient |
Data mining on these procedures and conditions can alert a plan to a provider performing an excessive number of procedures compared to their peers. It is also helpful to look at charge amount as well, since a charge much lower than the usual, customary and reasonable (UCR) fee could indicate a provider who wants to escape detection.
Once a provider is identified as having aberrant billing patterns, a health plan can take the following steps to protect its members:
- Put the provider on a watch list so that plan is alerted to any new claims.
- Stop auto-adjudicating of the provider’s claims.
- Perform an audit of the provider’s claims.
- Request medical records.
- Engage SIU investigators to confirm fraudulent activity.
- Take administrative and / or legal action.
Context4 Healthcare’s Payment Integrity Solution provides payers with a complete FWA investigation tool. Context’s FWA solution complements its industry leading pre-payment capability by allowing payers to perform provider FWA pattern recognition using claim data. Context’s Payment Integrity Solution can be a foundation to safeguard the health plan’s assets.
Context’s solution includes a library of algorithms and associated reports built around current FWA topics designed by our data scientists. We manage and update the algorithms weekly to allow payers to focus on their core business.
Each report provides a summary of the findings along with a capability to extract supporting data for further analysis. The library includes topics such as:
- Most frequently billed procedures by provider
- Highest charge procedures with provider detail
- Most frequent E/M encounters by provider
- Most frequent procedure for outpatient facilities by provider
- Highest charge procedure for outpatient facilities by provider
- Provider and Member Watch Lists
