For patients, fraud has dangerous implications

If identity fraud occurs, there are a number of negative repercussions for patient access, but this is also true for patients.

"There are potential financial implications when it comes to reimbursement," says Alesha N. Delgiacco, interim manager of inpatient access at Lancaster (PA) General Hospital. "There are serious and very dangerous implications when it comes to electronic medical records, if false names are used."

Access staff use the registration system to flag accounts if they suspect identity theft or insurance fraud. Each time the patient presents, the system sends a pop-up message, which prompts registration personnel to complete an action or ask a question.

"We have the potential to ward off the misuse of someone else's information on the front end, while the patient is still visual," says Delgiacco. "We contact security and get their involvement. Most 'fess up to the truth when confronted."

Therefore, patient access is able to bill correctly and update the "flagged" account. "Our goal is to give every patient the best care possible, despite their ability to pay," says Delgiacco. "Sometimes we are able to figure out the patient's financial needs and assist them with counselors while they are in the hospital."

The hospital's security department now gets involved in potential fraud cases. If fraud is suspected, all information is turned over to security for a follow-up. The legal department also reviews cases for potential follow-up actions.

"When we get a pop-up message, if we are unsuccessful in obtaining the correct answers to the questions, we involve security," says Delgiacco. "Our patient access department places a 'flag' on a record of potential or actual fraud."

Richard Pride, director of access management at University of Mississippi Medical Center in Jackson, says that the patient access department is the first line of defense for detecting fraud.

"Unless you use some electronic software that helps prevent fraud, you struggle to be accurate in detecting it," says Pride. "We are left with the questions we ask during the registration process as signals of an issue or recognizing that the driver's license or form of identity is fake."

Both come down to a gut feeling of the employee, which may or may not be correct, adds Pride. "Many more patients are arriving at the hospital that are out of jobs, which can lead to more attempts of fraud," says Pride.

The department's policy states that the employee is to immediately report any suspected case of fraud to his or her supervisor. The supervisor does a brief investigation to gather some facts, no longer than 30 minutes to an hour.

"The supervisor gathers the original information that made the staff suspicious that there could be an issue," says Pride. "It could be talking to a parent, friend, or the registrar to find out what triggered this patient as a concern.

"If we have any thoughts that it may be fraud, we are required to notify compliance and campus police," says Pride. "I believe it is important to gather this information while the patient is still present, although it does not usually occur that way. Usually, it is a parent or phone call that triggers that there is an issue."

For example, patients will call when they receive a bill and say that the bill does not belong to them. "That is enough to start an investigation," says Pride.

The hospital is in the process of purchasing a new electronic health record. "The plan is to include a software piece to detect fraud," says Pride. "We are leaning toward thumbprint recognition at this time, but a decision is still a few months away."

If the fraud goes unrecognized, Pride says that patient can potentially go all the way through the system on incorrect information. "This can affect many areas of treatment, including blood typing, allergies, and denials, just to name three," he says.

The department has had cases of a patient using a sibling's account. The blood bank goes to type and match the blood and it does not match what is in the system. "The blood bank must stop and we must go back and confront the patient," says Pride. "This causes a delay in treatment. But the consequences to the patient if [the wrong blood type] is given can be deadly."

[For more information, contact: Richard Pride, Director, Access Management, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Phone: (601) 815-1650. Fax: (601) 984-4881. E-mail: rpride@umc.edu.]