1. The Field of the Invention The present invention is directed generally to a healthcare monitoring system. More specifically, the present invention is directed to a mobile biometric home healthcare monitoring system to improve healthcare and prevent healthcare billing fraud.
2. Background Art
Fraud is a moving target as criminals shift to new and more sophisticated schemes as opportunities arise. Although a fraud may be corrected after it has been committed, the focus must be placed on prevention because the cost to recover losses may significantly outweigh the amount lost to the fraud itself. In many cases, once an improper payment has made due to fraud, only a small portion is ever recovered. The nation's ever-growing Medicaid budget echoes calls for the U.S. government to do more to combat fraud and incorporate greater technological approaches to keep up with sophisticated scams run by providers and recipients who take advantage of the current Medicaid program. The sheer size of the Medicaid program is one of the largest challenges that the nation faces. In New York state alone, there is a projected budget that exceeds $52.5 billion in fiscal year 2010-11 and more than one fifth of the state's population is enrolled in the Medicaid program. The size of this budget presents many opportunities for deception and dishonesty. While it is very difficult to determine an exact amount of Medicaid dollars lost to fraud, the estimates range from 3% to 10%. Based on this estimate, New York state taxpayers are losing between $1.5 and $5 billion each year and the American taxpayers are losing hundreds of billions of dollars nationwide annually due to fraud.
Criminals have developed numerous inventive ways to steal taxpayers' money. As the Medicaid system has grown in size and complexity, preserving the integrity of the program has become more challenging. One of the most common forms of Medicaid Fraud is false claim schemes, such as billing for services not provided. This very problem is the focus of the present invention.
Prior to the present invention, a telephonic delivery monitoring and verification program has been attempted to address Medicaid fraud. In November 2010, Sandata Technologies launched a fixed location tracking device in hopes of tying verification activities to locations. Both these systems help deter and prevent fraud, but are flawed since they are both pin based systems making it easy for anyone to enter the health provider's code.
Given the foregoing, what are needed are systems and methods for discouraging and preventing healthcare-related insurance fraud in ways superior to prior proposed solutions.
The present invention meets the above-identified needs by providing systems and methods for deterring and preventing, thereby reducing healthcare-related billing fraud.
In one aspect, the present invention provides a method for reducing healthcare fraud potentially committed by a healthcare worker and possibly the client the healthcare worker is assigned to care for as well. The method includes the steps of capturing and storing, in a central repository, a first biometric signature received of the healthcare worker. A first geographical location is provided based on the client location (or address). Then, during a visit to the client location, a second biometric signature of the healthcare worker is captured and received in the central repository. A second geographical location is then captured and stored in the central repository via a device from which the second biometric signature was captured and received. This is followed by the step of retrieving the first biometric signature and the first geographical location of the first client location from the central repository. Then, the first biometric signature is compared to the second biometric signature to produce a first result and the first geographical location is compared to the second geographical location to produce a second result to verify the eligibility of the healthcare worker in billing insurance provider for services purported to have been rendered. This allows an encounter record to be created in the central repository, wherein the encounter record comprises a first flag which indicates the results of the comparisons made.
Accordingly, it is a primary object of the present invention to provide a system and method that combines the use of biometric signature and location authentication to determine the presence of a healthcare worker at a client location during the period which the healthcare worker bills.
It is another object of the present invention to provide a healthcare fraud prevention system and method which utilizes at least one biometric signature matching to aid in reducing the ease with which the system can be tampered with.
It is another object of the present invention to provide a healthcare fraud prevention system and method which is not cumbersome to use, tamperproof and durable such that continual use of such a system is encouraged.
It is yet a further object of the present invention to provide a healthcare fraud prevention system and method that holds healthcare workers assigned to provide care to clients accountable and increases the quality of care to a client by ensuring that the healthcare worker assigned to the client is indeed present at the client's location.
Whereas there may be many embodiments of the present invention, each embodiment may meet one or more of the foregoing recited objects in any combination. It is not intended that each embodiment will necessarily meet each objective. Thus, having broadly outlined the more important features of the present invention in order that the detailed description thereof may be better understood, and that the present contribution to the art may be better appreciated, there are, of course, additional features of the present invention that will be described herein and will form a part of the subject matter of this specification.
In order that the manner in which the above-recited and other advantages and objects of the invention are obtained, a more particular description of the invention briefly described above will be rendered by reference to specific embodiments thereof which are illustrated in the appended drawings. Understanding that these drawings depict only typical embodiments of the invention and are not therefore to be considered to be limiting of its scope, the invention will be described and explained with additional specificity and detail through the use of the accompanying drawings in which:
The present fraud prevention system utilizes a combination of biometric signature and location authentication to verify the identity of a healthcare worker and that the healthcare worker is indeed present at a client's location when he or she bills for services purported to have been rendered at the client's location. The present system prevents payout of unauthenticated bills, therefore eliminating the efforts and expenses involved in making corrections on overpaid bills. Biometric signature authentication is more tamper resistant than a code protection system as anyone may enter a code using a keypad in response to a request to such code.
Another advantage lies in the ease of use. A healthcare worker or client is typically requested to provide a biometric signature for authentication. The location is automatically captured when a biometric signature is captured and both are sent to a central repository where an agency can access to monitor the healthcare worker and/or the client. The ease of use of additional authentication means also fall within the realm of abilities or the healthcare worker or the client. A healthcare worker or the client the healthcare worker cares for is requested via one of various means to respond to the request. Such request can be tailored to the ability of the client. A blind client, for instance, can be presented with an audio request instead of a visual request. On the other hand, a deaf client can be presented with a visual request instead.
Yet another advantage lies in the ability to authenticate the identity of the healthcare worker and/or the client when they are away from the client's place of residence, i.e., in exception cases. Under some Medicaid arrangements, clients are allowed to work away from home, carry out daily chores or spend time at recreational facilities while being supervised by a healthcare worker. As such, it is impractical to verify the absolute location of the healthcare worker and/or the client. The present invention provides a means to verify that the healthcare worker is in close proximity to the client after the healthcare worker requests for ensuing time period to be treated as an exception.
Yet another advantage lies in the ability to provide redundant means for verifying the presence of a healthcare worker at a client's location. If biometric signature authentication fails, a secondary means for authenticating the presence of the healthcare worker can be used. The second means include voice signature detection and the verification of a response to a request sent to the healthcare worker. Although the redundant means are used primarily in case the primary means for authentication, i.e., via biometric signature authentication, fails, the secondary means may also be used in cooperation with biometric signature authentication especially if suspicious behaviors of the healthcare worker have been previously detected.
Applicants discovered that device failure has been commonly cited as a reason for a healthcare worker to avoid using a verification tool assigned. The tampering of a device with the intent to either disable or replace one or more functions of the device is commonly done by the employee or healthcare worker to which the device is assigned such that the malfunction of the device can be used as an excuse to not perform a job the healthcare worker is assigned. Applicants discovered various means for detecting such an attempt which include detecting the power level of the device, electronically detecting case integrity of the device and repeated failure of biometric signature capturing effort.
The present invention is directed to systems and methods for deterring and preventing healthcare insurance fraud. Home healthcare is provided to individuals who need long term or short term care due to a medical condition such as reduced mental capability brought on by a trauma or disease. Such individuals or clients typically require special care which their family members are incapable of providing. As such, these individuals or their representatives seek help from Medicaid to provide home healthcare or supervision at a job. In one aspect, Medicaid delegates such responsibility to private healthcare agencies or hereinafter agencies to manage the healthcare needs of clients. An agency typically hires healthcare workers to care for the needs of clients. Such agency is in turn compensated by a Medicaid program based on the number of hours reported by the agency. The agency in turn compensates the healthcare workers based on number of hours worked. There exists opportunities for fraud in time reporting for compensation as it is not feasible for an agency to audit each home healthcare account due to distances or needs for privacy. Typical fraud committed includes but not limited to false reporting of time worked and unauthorized substitution of healthcare workers. The most common scenario for false reporting of time involves reporting of time period in which services were not actually provided to the clients. The most common scenario for substitution of healthcare workers occurs when the assigned healthcare worker uses an unauthorized or less qualified individual to provide care to clients. The applicants propose a solution which, if implemented properly, can aid in deterring or preventing such healthcare fraud involving home healthcare situations where their frequent supervision is not feasible or effective with existing systems. In some situations, clients cooperate with healthcare workers to defraud Medicaid in hopes that a portion of the ill gotten compensation from Medicaid be passed on to the clients. In one aspect, the present invention provides a means for validating the identity of an individual purported to be a healthcare worker and/or the identity of the individual purported to be a client the healthcare worker is assigned to provide care. In another aspect, the location at which care is provided is also verified. The present invention further provides a means to validate a healthcare worker and/or the client while care is provided at a location away from the client's home, an example of which occurs when the healthcare worker takes the client for a doctor's visit or a rehabilitation facility or even a recreational facility. The present invention is now described in more detail herein in terms of these contexts.
In one embodiment of the present invention, an additional identity validation means is provided to either serve as an additional or replacement validation means to the biometric signature means previously disclosed. In any case, a first and second geographical locations are still collected for verifying that the healthcare worker is present in the client's home while voice recognition is performed. Referring again to
The agency can then use the encounter record to determine whether the healthcare worker is eligible in collecting a payment for the time period in which services is purported to have been rendered. If the second flag indicates a match, the payment claim for the time period after step (d) is allowed. If the first flag indicates a mismatch for at least one of the comparisons, the payment claim for the time period after step (d) is refused.
In another embodiment, an additional validation means is provided to either serve as an additional or short term replacement validation means to the biometric signature means previously disclosed. In any case, first and second geographical locations also are still collected for verifying that the healthcare worker is present in the client's home while this validation means is performed. Referring again to
If the first timer expires before a response is received or if the received response does not match the request, the healthcare worker becomes ineligible to receive payment associated with the time period after step (d) of the visit.
In addition to the methods disclosed elsewhere in the disclosure, various provisions have been made in the present invention to prevent tampering of the device 30. The motivation behind device tampering typically is to either disable or replace one or more functions of the device such that the failure of the device can be cited as an excuse to not perform one's job. The healthcare worker assigned a device 30 is required to ensure the device 30 is properly powered such that the device 30 is functional when the it is expected to be used. The healthcare worker is required to place the device 30 in a charging configuration while not in use. For example, the device 30 can either receive wall power source to power an onboard battery charging device 84 through an AC/DC converter 88 or the battery charging device can be alternatively disposed outside of the device 30. In one aspect, a fully charged battery 86 typically can power the device 30 for about 2 days of continuous use without recharging. In the event that the battery 86 level is determined to be low by the battery monitoring device 84, a visual alert is provided on the touch screen display 40 to inform the healthcare worker of the low battery level status such that appropriate action can be taken (i.e., to place the device 30 in a condition to be recharged). The onset of a low power level or “battery low” condition is stored in the central repository 4. When the low power level condition no longer exists, the transition to “battery normal” power level is again stored in the central repository 4. The integrity of the present device 30 is ensured by electronically detecting case integrity of the device 30. The present device 30 comes in the form of a generally rectangular box with one accessible face which is normally protected with a lid, sealing the access and mechanically secured to the box. A case sensor 38 is mounted in a configuration such that when the lid is separated from the box, a “case open” condition is stored in the central repository. Further, the agency is capable of detecting repeated failure of biometric signature capturing effort. A repeated failure is defined as 3 attempts to validate biometric signature within 5 minutes. A “repeated failure” condition is stored in the central repository 4. Yet further, an agency subscribing to the present system can take advantage of the capability of the present system to detect multiple sets of billable hours, submitted to multiple agencies simultaneously, from one healthcare worker for a time period. In other words, if a healthcare worker attempts to submit more than one set of billable hours for a time period to multiple agencies, the present system which maintains all billable hours and biometric signatures from multiple agencies will flag this condition.
In situations during a visit of the healthcare worker where the healthcare worker and the client need to leave the client's location, an exception condition has to be logged. An exception condition is communicated via device 30 and stored in the central repository 4. In one embodiment, a button (software or hardware) is made available on the device 30 to enable entry or exit of the exception condition via the press of the button. Upon communicating this condition to the agency, the agency can then respond with a different validation strategy. Instead of tying the healthcare worker to the client's location, the validation strategy now switches to tying the location of the healthcare worker to the location of the client. In this exception condition, the client and the healthcare worker have moved from the client's home 28 to a second client location. In such an aspect, the following process as depicted in
If at least one of the fourth, fifth and sixth flags indicates a mismatch, the healthcare worker becomes ineligible to receive payment associated with a time period after step (g) of the visit.
As will be appreciated by those skilled in the relevant art(s) after reading the description herein, in an aspect, the web application described above executes on one or more web servers 54 (as shown in
As will also be appreciated by those skilled in the relevant art(s) after reading the description herein, in an aspect, the traffic 56 between the device 30 and a computer (e.g., web servers 54 and agency computer 14) or all other devices operably connected to the present invention is routed through one of the networks (e.g., cellular 22, Wi-Fi or Ethernet 24, modem 26, point-to-point 36) and the internet 10. In one embodiment, a public Branch exchange (PBX) 8 connects a client's phone line 12 via point-to-point 36 connection to an internal network 6 of the agency. The internal network 6 is operably connected to the web servers 54 which can be remotely located or locally located with the internal network 6. The internal network typically resides in a physical location of the agency. In one embodiment, one or more agency computers 14 may be connected directly to the internal network 6 or directly to the internet 10. The central repository 4 is operably connected to the web servers 54.
As will also be appreciated by those skilled in the relevant art(s) after reading the description herein, in an aspect, an application service provider (i.e., an entity providing the infrastructure for one or more healthcare agencies, insurers and/or recipients) with multiple locations at one or more corresponding URLs) may allow access, on a paid subscriber/membership, and/or pay-per-use basis, to the tools
(i.e., web application) the present invention provides for performing healthcare worker and/or client identity validation and eligibility verification.
The present invention (i.e., the process steps described above with reference to
Referring back to
The application software 108 also includes a time tracking system 112, a reporting system 114 for aggregating information pertinent to time periods of service and validation and verification status and an agency login interface 92 useful to facilitate login of an agency.
The web services 96 can include authentication and verification services 98, software or firmware automatic update services 102, device monitoring and status services 106, audio communication services 100, time tracking services 104 and cryptography services 34.
The time tracking system 112 provides a means to schedule a healthcare worker. A healthcare worker is typically allowed a certain number of billable hours in a time period, e.g., 70 normal billable hours, 30 overtime billable hours or 100 total billable hours in a week. The time tracking system 112 can be configured to receive the number of allowed billable hours per time period and the number of hours actually billed. A warning signal can be generated to alert the agency if a healthcare worker has exceeded or is approaching the number of allowed billable hours. Alternatively or in addition, an alarm can be set to alert the agency as the pace at which worked hours is accumulated exceeds a pre-determined rate, e.g., if a total allowed number of billable hours planned for a week has been approached within the first two days of the week, a condition is raised to the agency, healthcare worker and client to indicate a potential problem.
The time tracking services 104 serve as a time collector where events such as collections of biometric signatures and their corresponding geographical location data are time stamped such that a healthcare worker's reported time periods of service can be examined or verified. Referring to
The authentication and verification services 98 provide a means by which biometric signatures are verified, a means by which the proximity of the client to his responsible healthcare worker, a means to determine whether a healthcare worker is at a designated location during a billable period, etc. In the case of the healthcare worker is present but not able to verify his presence, the agency can resolve this issue by examining the time tracking services 104 and manually repair time recording. In case a healthcare worker is forced to log out, a signal is sent to flash the LED 42 on device 30. A notification is sent to the touch screen display 40 indicating that the healthcare worker account was logged out. The healthcare worker can re-log in and billable time will begin again and the agency will have the opportunity to modify time tracking for that healthcare worker. This situation may be most prevalent during overnight client visits where there may not be anyone at the agency to handle an alert immediately.
The cryptography services 34 provide a means by which encrypted communications between device 30, agency computer 14 and the web servers 54. The central repository 4 is operably connected to both the application software 108 and the web services 96 such that information pertinent to the time periods of healthcare workers, clients and their personal identification information can be stored and retrieved. The web portal 94 provides an interface where the agency can access via the agency's computer 14 and the internet 10 to take advantage of any of the services available in the application software 108 and the web services 96.
The device monitoring and status services 106 monitor and respond to any devices operably connected to the hardware platform 50, e.g., the biometric input device 62, accelerometer 32, case sensor 38, GPS sensor 58 and sensors or devices operably connected to the auxiliary input/output ports 90.
The device monitoring and status services 106 can also monitor distances traveled to ensure reimbursement of mileage is reported correctly by the healthcare worker. Geographical location information may be retrieved from the central repository 4 such that distances between locations can be derived and compared against the distances submitted to an agency for reimbursement.
Referring back to