Audio recording physician exams

Here’s a simple way to help prevent health care fraud. Patients, with their doctors’ consent, can audio record doctor visits with their smartphones. Audio recordings can verify bills submitted for health care services. And medical providers can upload and store audio files in patients’ electronic medical records to help ensure the veracity of physicians’ diagnoses and interventions.

Mabel Filldenshod, 67, a recently retired executive, is playing golf with some buddies. She’s on the fourth hole when she begins to have heart palpitations. She plays for another 15 minutes, but her heart is still thumping fast. So, one of her friends drives her to Filldenshod’s doctor. Dr. Flornusher runs an EKG, doesn’t find any problems with Filldenshod’s heart and proclaims her to be in fine health. Good news for Filldenshod but even better news for Dr. Flornusher.

After Filldenshod leaves, Dr. Flornusher bills Medicare for the EKG but also reports the visit as an appointment for a heart patient, which Filldenshod isn’t, but brings in more money for the doctor. That’s called upcoding, and it’s illegal.

Now, if Filldenshod had entered the examination room, pulled out her smartphone and told Dr. Flornusher she wanted to audio record their meeting for later clarification, Dr. Flornusher would’ve remained an honest man (at least this once), and he wouldn’t have ripped off taxpayers for some extra cash. This fictitious case represents one possible method for helping prevent some health care fraud — at least between medical workers and their patients during examinations.

Using everyday technology to fight health care fraud

Technology and our desire for fast-paced information have transformed the medical field. Doctors have tablets and laptops to record our medical information, and waiting rooms often have smartphone applications to advise us how long our wait will be. We can have video chats with our doctors and check our lab results online. We can email our doctors for medication refills or ask questions, and receive quick email responses. However, the ways we investigate health care fraud haven’t been so transformative.

Health care fraud costs are increasing around the world. It’s impossible to get a true estimate, but in the U.S. alone the FBI says it costs tens of billions a year.

Many federal and state agencies conduct consuming and complex health care fraud examinations, but with the development of electronic billing they often can’t show fraudulent physicians’ intent. Health care fraud occurs, in part, because a viable way to verify bills with services rendered doesn’t exist. Both government and private insurance companies utilize a “pay and chase model,” which means they pay every claim and only investigate claims that appear blatantly fraudulent. (See 23 Stunning Medicaid Fraud Statistics, HealthResearchFunding.org.)

One solution to this problem is audio recording medical treatment visits. Simple audio recording could prevent thousands of health care frauds and save millions.

(Find more health care investigative tools and resources in Nuts & bolts of health care fraud examinations, by Charles E. Piper, CFE, CRT. — ed.)

Audio recordings are tangible evidence of medical services rendered because they capture real-time visits between physicians and patients. They can verify bills physicians submit for health care services. And medical providers can upload and store audio files in patients’ electronic medical records to help ensure the accuracy of physicians’ diagnoses and interventions, and create objective records to verify the veracity of billings.

The recordings can help educate patients and protect physicians from false allegations and negligence claims, which costs malpractice carriers millions of dollars each year. In fact, doctors’ visits are already being recorded. However, the doctors’ offices aren’t doing the recording.

Audio recordings could reduce doctor misconduct

Doctors are already fearful patients are recording them. As of January, 77 percent of Americans own smartphones, according to a Pew Research Center report. And they’re nearly ubiquitous among younger adults — 92 percent of 18- to 29-year-olds own smartphones, all with the capability, of course, to audio record. (See Record shares of Americans now own smartphones, have home broadband, by Aaron Smith, Pew Research Center, Jan. 12.)

However, instead of fearing audio recordings, honest physicians should embrace them. Craig Klugman, Ph.D., assistant director for ethics education at the Center for Medical Humanities & Ethics at the University of Texas Health Science Center San Antonio, proposes that physicians should embrace recordings as do some police who are adopting body cameras to deter misconduct. (See Why Doctors Should Audio Record Patient Encounters, by Craig Klugman, Ph.D., Bioethics, April 29, 2015.)

It’s a plausible idea because data demonstrates that police departments that utilize body cameras see dramatic decreases in citizen complaints and use-of-force incidents.

During a February 2012-July 2013 study conducted by the Rialto (California) Police Department, half of its officers wore small cameras on their clothing or sunglasses, according to Wearing a Badge, and a Video Camera, Randall Stross, The New York Times, April 6, 2013. Even with only half of the 54 uniformed patrol officers wearing cameras, the department saw an 88 percent reduction in complaints filed, and the officers used force nearly 60 percent less often. The Rialto police chief said citizens often notice the cameras during encounters.

If physicians’ appointments with patients were audio recorded, we might see a similar reduction in patient complaints against physicians.

Katalin Eve Roth, M.D., J.D., division director of geriatrics and palliative medicine at George Washington School of Medicine and Health Sciences, believes “the ease of recording any encounter through technology with smartphones and tablets makes this question pressing and inevitable.” (See Pros and cons of letting patients record doctor visits, by Roth, amednews.com, Nov. 5, 2012.)

“A middle path that could avoid these risks while preserving the benefits might be to record only the beginning and end of the visit, leaving out the physical examination and providing patient and doctor with some privacy to discuss matters that should not be shared,” Roth writes. “In this case, the patient and physician would decide together what is to be recorded.”

The future of policing fraud is contingent on our ability to use innovation and technology to resolve major problems.

Patient privacy rights: a priority in California

Let’s turn the tables so medical personnel instead are making the recordings to protect their interests. A common initial concern is that audio recordings made by health care workers during patient visits violate patient privacy rights. However, as long as a patient has consented, the privacy of the audio recording would be protected; the recording would become a part of the patient’s medical record, which already has extensive privacy protections.

The U.S. Health and Insurance Portability and Accountability Act of 1996 (HIPAA) established strict privacy rights of citizens to protect their private health information. Information can’t be shared without the patient’s consent.

California, which has made patient privacy rights a priority, enacted legislation in 2008 to create a new state agency, Office of Health Information Integrity (CalOHII), with the primary mission of ensuring the enforcement of state law mandating the confidentiality of medical information.

Even with all these protections, however, private health information can still be compromised. Research shows several troubling data breaches involving health information that question the security of adding audio recordings to already vulnerable data.

In May 2015, UCLA Health Systems discovered that hackers had invaded its medical records system. The unauthorized access could have begun as early as September 2014, according to UCLA Health System data breach affects 4.5 million patients, by Chad Terhune, Los Angeles Times, July 17, 2015.

In March 2015, an employee of UC Irvine Medical Center accessed, without authorization, patient information including patients’ names, dates of birth, addresses, diagnoses, medical tests and prescriptions. (See Nearly 5,000 patients affected by UC Irvine medical data breach, by Chad Terhune, Los Angeles Times, June 18, 2015.)

And the giant health insurer, Anthem Inc., revealed in February 2015 that as many as 80 million people might have had their private medical information compromised in a another massive data breach. (See Anthem data breach could be ‘lifelong battle’ for customers, by Shari Rudavsky, INDYSTAR, Feb. 5, 2015.)

In February 2016, the Hollywood (California) Presbyterian Medical Center, was locked out of its own medical record system by ransomware. The hospital paid $17,000 in bitcoins to hackers to regain access and control over their medical records system. (See Hollywood Hospital Pays $17,000 to Ransomware Hackers, by Trevor Mogg, Feb. 18, 2016.)

Many companies still have encryption and data security deficiencies. However, data breaches alone shouldn’t deter moving forward with audio recording of medical treatment visits.

Embrace technological advances to combat medical fraud

The future of policing fraud is contingent on our ability to use innovation and technology to resolve major problems. Much of medicine has been digitized, from office visits to hospital records. Audio files are a natural progression from electronic medical records.

This is an opportune time to pursue audio recording. Consumers want their medical information at their fingertips. A 2012 research project, “Open Notes,” studied the impact of patients having rapid access to their office visit treatment notes. (See page 13 of “The Patient Will See You Now: The Future of Medicine is in Your Hands,” by Eric Topol, Basic Books, 2015.)

Three medical centers participated in the study — Geisenger in rural Pennsylvania, Harborview in Seattle and Beth Israel Deaconess in Boston. More than 100 primary care physicians and 22,000 patients embarked on an experiment to see what occurred when patients had immediate access to physician notes from their medical treatment visits.

Some physicians anticipated this practice would cause anxiety and confusion for patients and require the physicians to field more questions and messages from patients. However, the results disproved these doubts. Physicians were surprised it didn’t increase their workloads. Patients seemed more satisfied and engaged in their health care. They understood more of what they discussed during their medical visits and trusted their doctors more. Sixty-five patients were more compliant taking prescribed medications. Ninety-nine percent of the patients wanted this access in the future. Patients’ immediate access to their physicians’ notes is now standard practice at the three institutions where the study was conducted, according to “The Patient Will See You Now.”

If patients like seeing their physicians’ notes, they would value audio files even more. Patients are stressed and upset when they receive difficult diagnoses and often can’t retain critical information. But they can repeatedly access audio recordings when they’re calmer and able to make calculated decisions about their treatment options.

Incentives to implement medical audio recordings

State and federal governments won’t have to mandate audio recording of medical treatment visits with new legislation. Incentives will help patients to participate voluntarily.

Insurance companies could offer lower co-payments to consumers and higher reimbursement rates and lower malpractice premiums to physicians for participating in audio recordings of health care visits.

Because the investigation of complaints would be more expeditious and not use as many resources, state licensing boards could offer reduced annual licensing fees to those physicians if most of their patients agree to participate in audio-recording treatment visits. As fraud decreases, the overall cost of health insurance will decrease, which will benefit consumers.

A prescription for prevention

Audio recording of medical care visits can help patients better understand diagnoses and treatments. Physicians can be protected from unfounded allegations. Audio recordings can protect insurance companies because they know that bills submitted by physicians for services rendered can be verified. Law enforcement can find rock-solid evidence in audio recordings contained in patient records — a major deterrent to physicians and other health care workers contemplating fraud and an example of a path toward eradicating fraud in society.

Read more: "Crooked physicians and their code manipulation schemes"

Kathleen A. Nicholls, Associate Member, is deputy chief of the Health Quality Investigation Unit in the California Department of Consumer Affairs Division of Investigation. Her email address is: kathleen.a.nicholls@gmail.com.

This article is based on the author’s research she conducted as a part of the California Commission on Peace Officer Standards and Training (POST) and the Law Enforcement Command College. (The college is an 18-month program designed to prepare law enforcement leaders for future challenges, according to its website.)

“This article,” according to the author, “is a futures study of an emerging issue of relevance to law enforcement. Its purpose is not to predict the future but to project a variety of possible useful scenarios for planning and action in anticipation of the emerging landscape facing policing organizations.”
The views and conclusions here are those of the author and aren’t necessarily those of the California Commission on POST.

Crooked physicians and their code manipulation schemes

Fraudulent physicians or other primary providers knowingly enter incorrect diagnostic or procedural codes to obtain some benefit. Because the coding system can be complicated, providers, insurers and health care program employees often have difficulty identifying the codes that most accurately describe the services provided.

The process can be difficult because some coding systems attempt to identify codes for all accepted medical procedures, including codes to describe minor procedures that are components of more comprehensive procedures.

Payment policies add to the difficulty. For example, the fee for surgery often includes the cost of related services for the global service period (i.e., for a set number of days before and after the surgery). To prevent overpayment in these cases, health care programs and insurers need to identify when claims for surgery include codes that represent related services and reduce the payment accordingly.

It’s difficult for providers, insurers and health care programs to maintain proficiency in proper coding practices because a substantial number of the codes are changed periodically.

These complexities can inadvertently lead providers to submit improperly coded claims. They also make health care programs vulnerable to abuse from providers or billing services that attempt to maximize reimbursements by intentionally submitting claims containing inappropriate combinations of codes.

Unbundling charges and fragmentation

Because health care procedures often have special reimbursement rates for a group of procedures typically performed together (e.g., blood test panels by clinical laboratories), some providers attempt to increase profits by billing separately for procedures that are actually part of a single procedure. This process is called unbundling or coding fragmentation.

Simple unbundling occurs when a provider charges a comprehensive code, as well as one or more component codes. For instance, in the chart above, the provider would be overpaid because the fee for the total procedure already includes the value of its component parts.

Unbundling can be detected with computer programs that determine whether each code submitted is a component of one or more comprehensive codes.

Mutually exclusive procedures

A variation of unbundling, this scam involves billing for procedures that are either impossible to perform together or, by accepted standards, should not be performed together.

Global service period violations

Some dishonest providers will bill for a major procedure — such as a surgery — as well as related procedures when the fee for the major procedure already includes the fee for related procedures during the predefined period (the global service period). Detecting these abuses can be difficult because the fraud examiner must determine those services related to the surgery and those that aren’t. This difficulty is compounded by the fact that such services might be rendered by more than one provider.