The ITIJ team have been reporting from ITIC MEA 2023 in Abu Dhabi this week (15th May 2023) sharing the discussions that took place at the conference. Read all reports
In the second session, Shauna Vistad spoke about the types of fraud in the medical sector and advised how to recognise and address them.
Vistad said unnecessary testing is where providers play between different facilities. Providers order tests, but it is a separate lab that performs them. The lab will say ‘we can’t decide whether or not that’s medically necessary and appropriate; we did what the provider ordered us to do’.
Her solution for insurers is to remind the provider they’re responsible for doing medically necessary services under the terms of their contract: “If they’re routinely getting a test from a provider who is ordering medically unnecessary services, they need to put in some controls to make sure that they’re doing a double check on that provider before they continue to do business. But they are responsible for paying it back.”
Another aspect to be aware of is coding. A diagnosis cannot be given a code until it’s confirmed. Vistad questioned: “If I have confirmed the diagnosis, why am I performing the test? The purpose of the test is to determine what the cause of the condition is.
“If the first time a test is done, you’re seeing a confirmed diagnosis as a regular pattern of billing, that’s a provider I would look at because they’re probably running everybody through the same pattern of tests, trying to inflate their revenue from testing.”
Her suggestion is to refer providers to ICD-10 coding guidelines, if they follow international standard coding guidelines, insurers can apply that, and the provider should return the funds.
Looking for providers
Vistad’s recommendation is to look at providers doing the highest number of tests per patient and see whether they order the same panel of tests for every patient. She warned that providers will say they are testing to ensure quality of care for the patient.
She suggested to insurers when they evaluate, they should see certain processes: “They should really be saying something to the effect of ‘I think the patient might have X or Y or maybe even Z, and as a result, we’re going to do this diagnostic test and based on the results of that, we’re going to move to the next thing’, not ‘we’re just going to throw everything up there and see what sticks.’”
Insurers should remind providers their obligation is ‘to provide that clinical care for the patient and show them what their treatment plan should look like based on what they’re there to have serviced that particular day’.
Unnecessary lab testing
Vistad spoke about the rationale of testing due to significant antibiotic use. She explained a doctor said liver function tests were completed ‘just to be safe’, even though she hadn’t taken antibiotics in three years. She asked these questions: What do we want to define as significant antibiotic use? Do journal articles support this is a threshold at which it should be done? How many antibiotic prescriptions has the patient had in the last significant period of time? How frequently are they testing?
Another aspect is the use of multiple tests that give the same answer. Vistad said this was prominent during Covid-19, but questioned the motive: “Why do you need to confirm it was already positive?”
She admitted ‘on occasion, there may be a clinical reason to repeat a test, but it should be an exception, not the rule’. Her advice is to look for clinicians ordering similar tests all the time, how they’re going to use them and the information in the patient’s care plan. Also, see how they feed results back to the patient and how they used the results to inform clinical decisions.
“Is it a medical necessity or is it business?” said Vistad, as services should be based on medical necessity. However, patients move to new providers for faster treatment. Vistad explained new facilities are offering more complex treatment or testing that require conservative therapies, like Botox for excessive sweating and allergy testing.
She advised: “Take a look at the units of allergy testing being done and what policies state in regards to how long that conservative therapy comes up when you’re doing your data mining. Look back to before they transitioned to the new doctor to see whether they’ve ever reported signs before moving to the new doctor and jumping into diagnostic testing or treatment of a condition they’ve never said was a problem before.”
Same with cosmetic surgery, such as heavy eyelid surgery. “What we’ve been finding is as soon as we grab prior records, the patient clearly came in for cosmetic treatment and the visual obstruction is not documented enough to support the medical necessity of a treatment. It was very clearly a cosmetic procedure,” said Vistad. Insurers need to be aware of such claims and look for evidence this issue was reported to another clinician before.
To conclude the session, Chairman Ian Cameron asked: “Are you saying there’s never an occasion where a shotgun approach is appropriate?”
Vistad explained: “One of the things I’m looking for is patterns of behaviour. So, I’m looking for the clinician that’s always doing it as a shotgun approach and not using that thought basis. If they use the shotgun approach once or twice a year, that’s not a big deal – maybe it makes sense for that particular patient in that particular situation. But if I see a provider doing it every day, I would be concerned.”