Medical ID theft: Red flags and opportunities

As healthcare-related identity theft increases, insurers can educate providers on what telltale signs to look for to identify and prevent fraud, experts said during a question-and-answer session on a recent webinar co-hosted by the National Health Care Anti-Fraud Association (NHCAA) and FierceHealthPayer.

"What I would say to providers is don't be afraid to ask some tough questions," said Marita Janiga, J.D., executive director of the national special investigations unit and compliance hotline at California-based Kaiser Permanente.

Acknowledging that providers look at healthcare from a different lens than people working in the audit, investigations or risk environment, she recommended that if things don't look right to providers, they should ask questions and watch for the answers patients give. The integrated healthcare system also runs a number of algorithms in the background to detect signs like height and weight changes.

For potential identity fraud involving maternity services, for instance, Kaiser is looking for prenatal and postnatal care. "If a baby was born and there was no prenatal care, that's a red flag for us, or if there's postnatal care and there's no baby," Janiga said.

Meanwhile, industry initiatives around patient engagement present an opportunity for payers working directly with providers to get patients to validate current or prior services. "Anything that involves the patient associating services rendered in their name is an awesome way to mitigate someone's identity being stolen," said Rebecca Busch, RN, MBA, president and CEO of healthcare consulting, auditing and forensic services firm Medical Business Associates.

When asked who to reach out to for ID theft resolutions, Janiga said law enforcement has huge priorities and not every case will meet its threshold. She urged people to report any instance of medical ID theft to local law enforcement so it becomes a matter of record but noted that "it isn't the panacea for everything."

At Kaiser, certain issues rise to the top and need to be referred to law enforcement, with the concurrence of the chief compliance officer. But even if a case goes to law enforcement, the victim will still have a lot of work to do. "Just because the bad guy gets prosecuted and is put behind bars, doesn't mean the saga that that poor victim is enduring isn't going to go on," Janiga said.

In response to a question about removing identifiers, such as Social Security numbers, from medical records, Janiga said it is OK to do but won't eliminate medical identity fraud. "It's probably best to just not have it out there," she said.

For more:
- check out the webinar