The Language of Health Care: A Key Tool in Fraud Examinations

Health care is a $9.8 trillion business, according to the World Health Organization. In the U.S., according to the Centers for Medicare and Medicaid Services, health care is a $4.5 trillion business. Estimates of fraud in U.S. health care range widely, with one recent estimate being around $100 billion. Whichever way you analyze it, the losses and potential losses from fraud in health care are substantial. 

Know the Terminology 

For fraud examiners seeking to better understand the health care system and its complexity, it is important to appreciate the language that medical professionals use to get paid, and the systems, platforms and terms associated with the health care ecosystem. Definitions are crucial to understanding the landscape and making sense of key terms and their meaning.  

Since health care fraud is one of the largest fraudulent activities, Certified Fraud Examiners (CFEs) and fraud auditors who are not well versed in the health care industry can access multiple glossaries available on the internet to help them decipher information. You do not need to be a nurse or doctor to understand the business flow of a medical practice, but as all good auditors and fraud examiners know, it is essential to document how things actually occur as opposed to what the policy manual states—if there is one. Identifying and drilling down into gaps in policy, procedure and practice are critical to the discovery and remediation of fraud and misconduct.  

The Business of Health 

One of the most comprehensive glossaries is found at the U.S. Department of Health and Human Services (HHS), under the Assistant Secretary for Planning and Evaluation: Glossary of Terms | ASPE. The primary emphasis is on words associated with aging, disability or long-term care, but the list is extensive and incredibly useful for a variety of health care-related issues. Similarly, healthcare.gov has another Glossary of Health Coverage and Medical Terms that will be useful for a CFE working on these types of cases. 

The Practice Operations Glossary from the Medical Group Management Association is a useful tool to appreciate how medical practices operate from a business perspective. They include key terms like Total Medical Revenue and types of legal organizations. There is a separate Management and Staff Glossary that helps breakdown types of employees, geographic locations and types of specialties. 

At Doctors Management, they collected a variety of clinical and business terms in their Glossary of Terms that include HIPAA (the Health Insurance Portability and Accountability Act of 1996) Compliance, managed care, occupational health and safety, and others. 

Many providers, in helping their patients navigate the billing process, also provide terms and information about health care that can benefit fraud examiners. For example, the University of Washington Medicine published this Glossary of Billing and Insurance Terms to aid in patients interpreting their bills. 

Financial Recovery Group, a company specializing in health care information technology, created a glossary specifically dedicated to the issues of health care finance: Glossary of Medical Billing and Coding Terminology. Others, like professors at colleges or universities, have also done the same, like one from Dr. Marian Powers posted online at the University of Kansas Medical Center: Accounting Glossary for ASA.

Additional glossaries and terms can be found below: 

• Premera Blue Cross: Medical Reference Manual Glossary of Healthcare Terms 
• Anthem Blue Cross Blue Shield: Glossary of Healthcare Terms | Anthem 
• Commission for Case Manager Certification: ccmc-19-glossaryupdate.pdf 
• Snelling Center for Government: Glossary-of-Commonly-Used-Health-Care-Terms.pdf 
• Walker Company: Health Care ABCs - General Terms and Reform Terms 
• Health.mil (Military Health System): MHS Health Care Glossary | Health.mil 

Going Deeper 

Medical care is getting more and more complex—largely due to a massive increase in specializations and sub-specialties, which have their own language, too. If you are working a case on an oncologist, audiologist or a durable medical equipment provider, it would be important to identify those specialty-specific jargon. Below are some examples: 

• Clinical research terms: NIA Glossary of Clinical Research Terms | National Institute on Aging 
• Psychiatric/Mental Health: Glossary of Terms – Rogers Behavioral Health and here. 
• Dental: Glossary of Terms - AAOMS | AAOMS 
• Surgery: General Surgery Practice of NNJ - Glossary 
• Plastic Surgery: Plastic Surgery Glossary | American Society of Plastic Surgeons 
• Orthopedic: Glossary of Orthopaedic Terms - Orthopaedic Specialists of Metropolitan Washington 

Finding More Resources 

Local public and university libraries also have excellent resources in their holdings that can be useful in a health care fraud examination. Many local libraries also have access to national databases that could provide additional information and context that a CFE would find beneficial during an engagement. Used book sellers, both physical and online, should not be overlooked for low-cost publications. 

Open-source books by reputable professionals, like university professors, will also come in handy. For example, two University of West Florida instructors have published the “Medical Terminology for Healthcare Professions.” 

Applications in Real Life 

Terms and their definitions are not just for the theoretical understanding of a situation but can be employed during a fraud examination or investigation in a variety of ways. Some instances include: 

• Using terms to test the accuracy of your understanding—or the interviewee’s. (e.g., What is an adenoidectomy, Dr. Smith? What does it mean? Help me understand what [term] consists of…) 
• Define the terms for a lay audience, such as a prosecutor or attorney, if they do not specialize in medical or health care fraud. (e.g., Palliative care is defined as medical care focused on improving quality of life for people with serious illnesses and their care partners by the National Institute of Health…)
• Explaining the term and its usage in a presentation, trial testimony or investigative report so that it sets the conduct into its proper context. (e.g., Palliative care and hospice care are often intertwined; according to the National Institute of Health, hospice care only occurs at the end of someone’s life, while palliative care can be done anytime during a serious illness, regardless of its terminal nature…) 

Music is a universal language—a cellist does not need to know the trumpeter’s native language to be able to play the instruments together. Much like an orchestra, it is important for fraud examiners, investigators and auditors to be on the same page, especially when dealing with the complexity and depth of health care. Comprehending the terms, acronyms and jargon of the healing profession is vital to be able to accurately and adequately conduct a fraud examination in this industry.