There are many techniques to extracting data that can range from reviewing claim line billing data to actual medical record reviews. Relying exclusively on the claims data to analyze and identify atypical billing patterns or potential red flags is always challenging. As auditors we all know that the value of the audit process is only as good as the information extracted from the data or medical record.

The most significant aspect to successfully auditing claims data is in the manipulation, sorting and filtering of it in order to display the data in a more logical format.

By examining claim line billing data you can identify:

  • Excessive billing: Same diagnosis, same procedure.
  • Excessive number of procedures: Per day or place of service per day/per patient.
  • Multiple billings of same procedures, same date of service.
  • Frequency of high level Evaluation and Management Services; Statistically outlying numbers
  • Duplicate billings
  • Gender related inappropriate billings of procedures
  • Age related inappropriate billing of procedures
  • Fraudulent family members; i.e., three dependent children born within a two year period
  • Mutually exclusive procedural combinations
  • Unbundling or billing separately for laboratory tests performed together
  • Inappropriate application of Modifiers 25 and 59; i.e., no NCCI edits

This method of reviewing claim line data can identify high risk billing and coding areas as well as potential fraud, waste and abuse.

Analytical techniques for Fraud Detection require an understanding of:

  • The areas in which fraud can occur
  • What fraudulent activity would look like in the data

The “red flags” identified through claim line data review typically require further investigation by way of a medical record review in order to provide a more detailed analysis of the findings.

If you have questions regarding auditing claims data, contact us.