Medical Incite Case Study: Hospital Billing Fraud

Issue:
Client suspected that staff members were violating billing rules in certain hospital departments. The challenge was to verify if the violations were fraudulent or an accounting oversight. 

Application:
Billing Forensics Model - using Medical Incite, our statisticians worked with client administrators to mine and model their patient records and hospital service codes by department.  

Solution:
Using the data indicated above, we isolated the services in each department that were most associated with billing violations. Our staff then used these findings to “map” staff behavior as it related to the violations and analyze the behavioral interdependencies between the departments contributing to the violations. It was determined that due to limitations in the clinical service entry forms, the staff could not accurately account for their time. To override this issue, they were re-entering the same clinical service data on a new form. The multiple billing entries for the same clinical treatment triggered the fraudulent billing codes. As a result, new codes have been introduced which enable the staff to account for their clinical service time without restrictions.

The first screen shot below shows the Medical Incite model that identified the billing problem. The second screen shot identifies the procedure that accounted for the clinical service time issue.