Patent Application
20070294104
The embodiments of the invention will be better understood from the following detailed description with reference to the drawings, in which:
The embodiments of the invention and the various features and advantageous details thereof are explained more fully with reference to the non-limiting embodiments that are illustrated in the accompanying drawings and detailed in the following description. It should be noted that the features illustrated in the drawings are not necessarily drawn to scale. Descriptions of well-known components and processing techniques are omitted so as to not unnecessarily obscure the embodiments of the invention. The examples used herein are intended merely to facilitate an understanding of ways in which the embodiments of the invention may be practiced and to further enable those of skill in the art to practice the embodiments of the invention. Accordingly, the examples should not be construed as limiting the scope of the embodiments of the invention.
As mentioned, there remains a need for a method and system for detecting medical insurance fraud. The embodiments of the invention achieve this by providing a method for detecting medical insurance and health care fraud. Referring now to the drawings, and more particularly to
The high cost of medical care and the low rates of insurance coverage have set the conditions for widespread insurance fraud in medical care. Furthermore, the forthcoming adoption of modern information technology applied to electronic health records and payments may accelerate the threat of insurance fraud. Fraud and abuse take place at many points in the health care system including doctors, hospitals, nursing homes, diagnostic facilities and pharmacies, for example. Health care is especially susceptible to electronic data interchange fraud. Thus, implementation of methods to identify and prevent medical insurance fraud will help to keep health insurance costs down and protect a patient's medical history and privacy.
As the U.S. and other countries around the world move to modern electronic health records, the ability of criminals to steal or otherwise misappropriate insured patient identities, and therefore, to make fraudulent claims against the patient's insurance policies will become an increasing threat. The efficiency of electronic information systems vastly increases the rate at which this type of fraud can cause monetary including damage to the patient's identity and health record itself. The present invention uses the patient's own medical information to protect against such fraud.
By its very nature, healthcare, and therefore electronic health records is distributes. A modern information system for managing health records in the U.S. will require that patients have access to a registry of metadata that indirectly points to the locations where their records are stored. With the invention, this registry is stored on a smart card, a Universal Serial Bus (USB) Key, a Personal Computer (PC), magnetic strip card, or other pervasive device. The data could also be stored on-line in the patient's independent account at a health record bank. Any time the patient goes to a medical care provider for services, the medical care provider can access some parts of this data to support the continuity of patient care. The provider also can access the patient's identification and medical history for billing and payment purposes.
Identity theft and stolen insurance information will become vastly more damaging once electronic health records and payment systems become ubiquitous. Furthermore, the large number of uninsured in our society may cause some, out of desperation, to use counterfeit health insurance cards or use stolen insurance information to obtain care; thus, passing the cost of theft on to the insurance companies, the providers and other insured patients.
Unlike fraud involving financial systems, medical insurance fraud can take place based on the fact that individuals hold more than one insurance policy and visits various medical care providers. In medical fraud there is a more complex range of preventable crimes based on use of the coded entities in a patient's health record. The range of medical fraud that may be prevented includes: charging the same treatment to multiple policies; charging for incompatible treatments; using multiple policies and multiple providers to obtain drugs that may, for example, then be sold; and identity theft across policies.
In financial systems, one does not see data or information being added to a particular individual's record. In other words, the victim of fraud would not see information, i.e. money, added to his bank or credit card account. Generally, in credit card or bank fraud, the victim sees money removed from his account. In health records, data may be added or removed in order to perpetuate fraud of an individual or of a company without the victim's knowledge. For instance, fraudulent deposition of a misdiagnosis could be used to gain access to healthcare or medications. For example, one having fraudulent intent could add a record that he has chronic back pain and must be prescribed a potent pain medication. The individual could then obtain a prescription for that medication based on the fraudulent record one in which data has been deposited. Another example would be someone with a diagnosis that would preclude some sort of health benefit or treatment. In such a situation, an individual might want to “deposit” a second diagnosis that contradicts the first or remove the unwanted report. Thus, in health care fraud, the complexity of the health care system makes the detection of fraud a challenge.
The method detects and prevents fraudulent medical insurance claims by storing identifying information and medical transaction histories on both a portable storage device and on a server (100). The portable storage device (200 in
The stored information and histories on the device and the server are compiled from a plurality of sources (102). Those sources include various medical care providers including, but not limited to, primary care physicians, specialists, pharmacies, hospitals and laboratories. A patient user presents the portable device to a medical care provider at the time of receiving medical services, medical supplies, medicines, etc. (104). When the patient presents the portable device, the stored information and medical history stored on the server is detected (read) (106).
The information and medical histories on the portable storage device presented by the patient can be handled by a healthcare provider transaction processor and validator. As shown in
When the information on the portable device show inconsistencies of either added or deleted data, potential medical insurance fraud is indicated by the inconsistent data. An alert to potential fraud is triggered on the server and/or portable device. Additionally, the alert is also beneficial in circumstances where inconsistencies in drug dosage are noted by detecting inconsistencies in the records, for example. The detection of the inconsistency, in addition to preventing fraud, alerts the medical care provider to potential medical errors.
In circumstances were the information and medical histories on both the portable storage device and the server are the same or consistent with each other, the information and medical histories on each device are updated to include the current transaction the patient is requesting on presentation of the portable storage device. The provider accesses the patient's information and medical history on the portable storage device present at the time of service. The payor matches the local history from the patient's portable device with the history data on the server. If the information and histories on the patient's device and the information from the server accessed by the provider's transaction processor and validator match, the transaction is considered valid. The provider approves the treatment and sends a message, e.g. a bill, which updates the payor's registry and also the server. That information is communicated to the server and the portable device to update the patient's identifying information and medical histories on each device. Both the provider's process validator and the payor's process validator communicate with the server to access the patient information and medical history because the system may detect medical fraud even in instances where insurance is not involved.
In an example of a fraudulent encounter, a criminal organization or individual steals or otherwise misappropriates the patient's identifying information and medical history or makes a counterfeit copy of the patient's portable storage device. A copy of the patient's device is made. The copied device is presented to a provider. The provider accesses the patient's identifying information and medical history from the device and the server. The provider or payor matches the local history from the patient's portable device with the history data on the server. Data from the copy is considered valid, so provider approves treatment. The provider sends a message, e.g. a bill, that updates the server and the patient's personal registry on the copied device with a reference to the new encounter with a medical provider for services. The data on the counterfeit device is now out of synch with the data on the actual patient's own copy of his medical history on his portable device. The very next time the patient sees a provider the provider and payor system will discover the synchronization error and inform the patient of the possible fraud. If multiple counterfeit copies are used, the first time a single counterfeit device is used all counterfeit devices become out of synch. Thus, the fraud is contained to the use of the illegal counterfeit use of a single copy of the patient's information and history from his device. The fraud is automatically detected any time a second a device is used. The more widespread the counterfeit, the faster the fraud is detected with the present method.
Fraud can be detected even more quickly than described above using direct messaging between the patient's device and the server. With each encounter for medical services the patient can be notified electronically of the new encounter and thus be informed on the very first fraudulent use or billing to a health insurance policy.
The embodiments of the invention can take the form of an entirely hardware embodiment, an entirely software embodiment or an embodiment including both hardware and software elements. In a preferred embodiment, the invention is implemented in software, which includes but is not limited to firmware, resident software, microcode, etc.
Furthermore, the embodiments of the invention can take the form of a computer program product accessible from a computer-usable or computer-readable medium providing program code for use by or in connection with a computer or any instruction execution system. For the purposes of this description, a computer-usable or computer readable medium can be any apparatus that can comprise, store, communicate, propagate, or transport the program for use by or in connection with the instruction execution system, apparatus, or device.
The medium can be an electronic, magnetic, optical, electromagnetic, infrared, or semiconductor system (or apparatus or device) or a propagation medium. Examples of a computer-readable medium include a semiconductor or solid state memory, magnetic tape, a removable computer diskette, a random access memory (RAM), a read-only memory (ROM), a rigid magnetic disk and an optical disk. Current examples of optical disks include compact disk—read only memory (CD-ROM), compact disk—read/write (CD-R/W) and DVD.
A data processing system suitable for storing and/or executing program code will include at least one processor coupled directly or indirectly to memory elements through a system bus. The memory elements can include local memory employed during actual execution of the program code, bulk storage, and cache memories which provide temporary storage of at least some program code in order to reduce the number of times code must be retrieved from bulk storage during execution.
Input/output (I/O) devices (including but not limited to keyboards, displays, pointing devices, etc.) can be coupled to the system either directly or through intervening I/O controllers. Network adapters may also be coupled to the system to enable the data processing system to become coupled to other data processing systems or remote printers or storage devices through intervening private or public networks. Modems, cable modem and Ethernet cards are just a few of the currently available types of network adapters.
A representative hardware environment for practicing the embodiments of the invention is depicted in
A representative hardware environment for practicing the embodiments of the invention is depicted in
The foregoing description of the specific embodiments will so fully reveal the general nature of the invention that others can, by applying current knowledge, readily modify and/or adapt for various applications such specific embodiments without departing from the generic concept, and, therefore, such adaptations and modifications should and are intended to be comprehended within the meaning and range of equivalents of the disclosed embodiments. It is to be understood that the phraseology or terminology employed herein is for the purpose of description and not of limitation. Therefore, while the embodiments of the invention have been described in terms of preferred embodiments, those skilled in the art will recognize that the embodiments of the invention can be practiced with modification within the spirit and scope of the appended claims.
