Indicators of Diagnostic Testing Fraud 6-18-15

1 Indicators OF Diagnostic Testing Fraud Detection - The First Line of Defense ost claims are legitimate, but some are fraudulent. Therefore it is appropriate to review all claims for possible Fraud . Detecting Fraud is aided by familiarity with industry identified Fraud Indicators . ndicators assist in the identification of claims which merit closer scrutiny. The presence of an indicator (or several Indicators ) do not prove Fraud . Indicators of possible Fraud are not actual evidence, they only "indicate" the need for further investigation. ome claims, although questionable, may be paid due to a lack of conclusive evidence of Fraud . However, they should be submitted as questionable claims to NICB for further review.

2 For additional information on the following Indicators , please see the NICB s Interactive indicator Guide. This Guide is a software application providing the concern associated with each indicator as well as suggested resolution steps. For access to the Interactive indicator Guide, please contact NICB s Training Department. Regarding Diagnosis A test or series of Diagnostic imaging tests is given to all patients at a clinic or medical office regardless of injury. Bills for Diagnostic imaging are submitted without supporting documentation such as reports. Comparison Diagnostic tests are ordered by provider ( performing a Diagnostic test on an uninjured joint so the results can be compared to the Diagnostic test results from the injured joint).

3 Computer Topography (CT or CAT) scans with multiple views when single view ordered. Diagnostic imaging is not consistent with the nature of the injury or treatment. Diagnostic imaging is performed on several visits rather than one. Diagnostic test ordered not normally associated with the reported injury (soft tissue injury with hair analysis, allergy Testing , saliva Testing , balance Testing , etc.). Diagnostic Testing (X-rays, EMG Testing , MRIs, etc.) is performed often and early in the treatment. Diagnostic Testing is billed repeatedly without a report of a worsening condition in objective findings or a report of a new injury. Digital analysis of plain film radiography.

4 Discrepancies exist between the locations of Diagnostic imaging Testing (and other types of tests) and the person interpreting the test. Electrocardiograms (ECGs or EKGs) are administered to patients with no complaints or conditions. Evidence exists of payments/commissions from Diagnostic test provider to the ordering practitioner. Experimental Testing - (Surface Electromyography (sEMG), Quantitative Sensory Testing (QST), Current Perception Threshold (CPT), Voltage Actuated Sensory Nerve Conduction Threshold (VsNCT). Full spine x-rays on each and every patient on the initial exam and then again at the reevaluation. Insured questions the amount of Diagnostic imaging tests ordered.)

5 Medical records do not explain excessive, expensive medical Testing /treatment. Mobile unit performs neurological or other tests, which are read at remote locations. Multiple Diagnostic procedures are billed with separate CPT codes when there is a CPT code that includes all of the billed procedures. Non- Diagnostic quality tests ( full spine x-rays, poor quality ultrasound, EMG poor technique). Ordering nerve tests ( Electromyograph - EMG, Nerve Conduction Velocity - NCV) in the absence of clinical evidence of nerve injury or disease. Patient does not know the result of the Diagnostic test(s).. Surface EMGs (SEMG) are used for diagnoses.

6 Ultrasound of entire abdomen scan when quadrant scans ordered. M I SRegarding Facility/Operation Billing from the MRI facility for 3D imaging and the reading of the 3D film when the facility does not have the appropriate computer program to create or read it. Equipment and treating facility is out-of-date, broken, or inconsistent with treatment billed. MRI (Magnetic Resonance Imaging) facilities misconstrued as medical facilities that are not owned by a licensed medical professional. MRI imaging center billing, writing report, but not performing unique exam. Modifying the DICOM data files. Mobile imaging used when fixed higher quality centers locally available.

7 New or unknown Diagnostic clinic/center. The word Diagnostic appears in the name of the facility submitting the medical bill. There is no indication that very high tech equipment such as MRIs and X-ray machines are maintained and calibrated. Regarding Medical Bills Billing and coding for cervical, thoracic, and lumbar x-rays when a full spine x-ray was performed. Billing for quantitative Testing but performing qualitative Testing . Billing for thermography studies. Bills include high dollar additions for off-site system and surgical monitoring for surgical procedures ( by doctors who are not even in the room at the time of the surgery).

8 MRI bills appear early on in the treatment and repeated again in later treatment. Provider bills for medical tests or evaluations that were not conducted. Provider bills global codes then later billing separately for the technical or professional component. Provider bills global Diagnostic CPT code without the necessary Diagnostic equipment ( an x-ray machine) located at the provider s facility. Use of a Technical (TC) or Professional (PC) component modifier with a Diagnostic procedure CPT code billed in conjunction with the applicable global Diagnostic CPT code. Regarding Medical Fraud /Claim Inflation Medical history for patient not present in the documentation.

9 No changes in treatment plan after several treatment sessions have been rendered and extensive Diagnostic Testing (EMG, NCV, MRI, etc.) is performed. Regarding Medical Treatment Medical treatment is given by receptionists or other non-medical personnel. Provider repeatedly uses x-rays, ultrasounds, nerve conduction tests, or spinal video fluoroscopy to check treatment progress. The treatment plan does not change over time (especially if additional Diagnostic tests have been done). Regarding Professional Issues Diagnostic tests performed but not read or interpreted by qualified medical personnel. Regarding Specific CPT Codes Biofeedback (90901) is performed on all of a provider s patients.

10 Digital analysis of electroencephalogram (97957) routine appearance on bills. Needle EMG (95860 single extremity) multiple times per visit. Needle EMG (95864) all four extremities (without justification documentation). Nerve conduction (*95907 and *95913) Testing on the same bill for the same nerve (95913 includes 95907). Nerve conduction tests (*95907 and *95913) billed multiple times for the same nerve. Nerve conduction tests (*95907 and *95913) show the same results across patients. National Insurance Crime Bureau Des Plaines, IL 60018 1-800-447-6282 Copyright 2015 All rights reserved *New CPT codes (95907 and 95913) replace deleted codes (95900 and 95903) CPT Assistant March 2013 CPT 2013 Code Book