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Insurance Abstract
The invention provides a method for detecting and preventing fraudulent
medical insurance claims comprising storing identifying information
and medical transaction histories on a portable device and on a
server. The portable device is presented by a valid patient user
to an authorized medical care provider. Medical transaction histories
stored transaction histories are detected from the portable device
and server. Medical transactions histories stored on the device
are compared with those stored on the server. When the transaction
histories on each device do not match, potential fraudulent medical
insurance claims are detected.
Insurance Claims
1. A system for detecting medical record inconsistencies comprising:a
portable device adapted to be carried by a patient and to store
identifying information and medical transaction histories;a server
adapted to store said identifying information and medical transaction
histories;a portable device reader connected to said server, wherein
said portable device is adapted to temporarily connect to said portable
device reader; anda comparator connected to said server and adapted
to compare said identifying information and said transaction histories
stored on said portable device and stored on said server.
2. The system of claim 1, further comprising a transaction process
validator connected to said portable device and said server.
3. The system of claim 1, further comprising a compiler connected
to said server and adapted to compile said identifying information
and said medical transaction histories from a plurality of medical
insurance policies, and medical care providers.
4. The system of claim 1, wherein said server is adapted to update
said identifying information and said medical transaction histories
on said portable device and said server when said identifying information
and said medical transaction histories on said portable device and
said server are consistent with each other.
5. The system of claim 1, said server is adapted to not update
said identifying information and said medical transaction histories
on said portable device and wherein said server when said identifying
information and said medical transaction history on said portable
device and said server are not consistent.
6. The system of claim 1, wherein said server is adapted to produce
an alert on said portable device and said server when said identifying
information and said medical transaction history on said portable
device do not match said identifying information and said transaction
histories stored on said server.
7. An apparatus for detecting medical record inconsistencies comprising:a
portable device adapted to be carried by a patient and to store
identifying information and medical transaction histories in a rewritable
electronic memory,wherein said portable device is adapted to connect
to a system comprising:a server adapted to store said identifying
information and medical transaction histories;a portable device
reader connected to said server, wherein said portable device is
adapted to temporarily connect to said portable device reader; anda
comparator connected to said server adapted to compare said identifying
information and said transaction histories stored on said portable
device and stored on said server.
8. The apparatus of claim 7, wherein said connector comprise at
least one of a physical connection and a wireless connection.
9. The apparatus of claim 7, further comprising a compiler connected
to said server and adapted to compile said identifying information
and said medical transaction histories from a plurality of medical
insurance policies, and medical care providers.
10. The apparatus of claim 7, wherein a transaction processor and
validator are connected to said portable device and said server.
11. The apparatus of claim 7, wherein said portable device and
said server are adapted to compile said identifying information
and said transaction histories from a plurality of medical policies
and a plurality of medical care providers.
12. The system of claim 7, wherein said server is adapted to update
said identifying information and said medical transaction histories
on said portable device and said server when said identifying information
and said medical transaction histories on said portable device and
said server are consistent with each other.
13. The system of claim 7, wherein said server is adapted to not
update said identifying information and said medical transaction
histories on said portable device and said server when said identifying
information and said medical transaction history on said portable
device and said server are not consistent.
14. The system of claim 13, wherein said server is adapted to produce
an alert on said portable device and said server when said identifying
information and said medical transaction history on said portable
device do not match said identifying information and said transaction
histories stored on said server.
15. A method for detecting and preventing fraudulent medical insurance
claims comprising:storing medical transaction histories on a portable
device and a server;comparing said medical transaction histories
on said portable device with said medical transaction histories
on said server; andresponsively noting inconsistencies between said
medical transaction histories on said portable device and said server.
16. The method of claim 15, wherein said inconsistencies indicates
one selected from: fraudulent inconsistencies and erroneous inconsistencies.
17. The method of claim 16, wherein said fraudulent inconsistencies
in said medical transaction histories includes at least one selected
from the group of: added data and deleted data.
18. The method of claim 15, wherein said transaction histories
are complied from multiple medical insurance policies or multiple
medical service providers.
19. The method of claim 16, wherein said fraudulent inconsistencies
are detected when a valid user attempts to update said medical transaction
histories after an unauthorized user has updated said medical transaction
histories and said medical transaction histories on said portable
device does not match said medical transaction histories on said
server.
20. The method of claim 16, wherein said erroneous inconsistencies
are detected when a valid user attempts to update said the medical
transaction histories and said medical transaction histories on
said portable device and said medical transaction histories on said
server do not match.
Insurance Description
BACKGROUND
[0001]1. Field of the Invention
[0002]The embodiments of the invention generally relate to health
care fraud detection, and, more particularly, to a method and system
for detecting fraudulent medical insurance claims by providing a
patient user with a portable device storing the user's identification
information and the user's medical history. Portable devices may
include, for example, a smart card, a flash memory device, a magnetic
strip card, etc. A remotely located server also stores the information
and history. Potential medical fraud may be identified by detecting
inconsistencies in the information and histories stored on the server
and portable device.
[0003]2. Description of the Related Art
[0004]In the health care industry electronic means for storing
medical information include electronically storing data on a mainframe
computer, computer server or LAN within a medical provider's locality,
for example, hospital, physician's office, laboratory, pharmacy,
etc. Because the information is stored locally, there exists a risk
of fraud. If a patent's information is stolen or modified from one
provider and used elsewhere to obtain medication, for example, it
is very difficult to adequately identify that any fraud has occurred.
Another risk inherent in such systems is miscommunication, misunderstanding
or lack of knowledge of past medical problems and procedures by
the varied medical care providers storing patient data and medical
histories. The health care providers can make diagnoses and prescribe
treatment with less than the totality of the patient's medical and
treatment history.
[0005]Fraud and abuse may take place at many points in the health
care system. doctors, hospitals, nursing homes, and diagnostic facilities,
for example. Health care is especially susceptible to electronic
data interchange fraud. Electronic data interchange (EDI) is the
direct filing of claims, computer to computer, and is widely used
for Medicare claims. Thus, given the growing number of claims sent
electronically, improved methods for identifying and preventing
fraud particularly in the health care system are needed.
SUMMARY
[0006]In view of the foregoing, an embodiment of the invention
provides a method for detecting and preventing fraudulent medical
insurance claims comprising storing identifying information and
medical transaction histories on a portable device and on a server.
The portable device is presented by a valid user, e.g. patient,
to an authorized entity, e.g. physician. Stored medical transaction
histories are detected from the portable device and server. Medical
transactions histories stored on the patient's device are compared
with those stored on the server. When the transaction histories
on each device do not match, fraudulent inconsistencies, e.g. potential
fraudulent insurance claims, are detected.
[0007]In another aspect of the invention, the medical transaction
histories of a patient user are compiled from a plurality of sources.
A patient may be covered by multiple insurance policies and visit
various medical care providers. Therefore, it is advantageous that
a system and method be able to compile information from many sources.
Moreover, individuals see various medical care providers for their
health care needs. In this method, the information is collected
from the various medical care providers, for example, primary care
physicians, specialists, laboratories, pharmacies, etc. Thus a complete
medical transaction history is stored in both the portable storage
device and the server.
[0008]In yet another aspect of the invention, the patient user
presents the portable storage device to a medical care provider
who downloads the information and histories from both the portable
device and server. When the information and histories are compared.
If the information and histories match, the medical transaction
histories on both the portable device and the server are updated
to include the most recent medical transaction.
[0009]These and other aspects of the embodiments of the invention
will be better appreciated and understood when considered in conjunction
with the following description and the accompanying drawings. It
should be understood, however, that the following descriptions,
while indicating preferred embodiments of the invention and numerous
specific details thereof, are given by way of illustration and not
of limitation. Many changes and modifications may be made within
the scope of the embodiments of the invention without departing
from the spirit thereof, and the embodiments of the invention include
all such modifications.
BRIEF DESCRIPTION OF THE DRAWINGS
[0010]The embodiments of the invention will be better understood
from the following detailed description with reference to the drawings,
in which:
[0011]FIG. 1 is a flow diagram illustrating a preferred method
of an embodiment of the invention;
[0012]FIG. 2 illustrates a schematic diagram of a hardware system
for the practice of the present invention; and
[0013]FIG. 3 illustrates a schematic diagram of a system for the
practice of the present invention.
DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS
[0014]The embodiments of the invention and the various features
and advantageous details thereof are explained more fully with reference
to the non-limiting embodiments that are illustrated in the accompanying
drawings and detailed in the following description. It should be
noted that the features illustrated in the drawings are not necessarily
drawn to scale. Descriptions of well-known components and processing
techniques are omitted so as to not unnecessarily obscure the embodiments
of the invention. The examples used herein are intended merely to
facilitate an understanding of ways in which the embodiments of
the invention may be practiced and to further enable those of skill
in the art to practice the embodiments of the invention. Accordingly,
the examples should not be construed as limiting the scope of the
embodiments of the invention.
[0015]As mentioned, there remains a need for a method and system
for detecting medical insurance fraud. The embodiments of the invention
achieve this by providing a method for detecting medical insurance
and health care fraud. Referring now to the drawings, and more particularly
to FIGS. 1 through 3, where similar reference characters denote
corresponding features consistently throughout the figures, there
are shown preferred embodiments of the invention.
[0016]The high cost of medical care and the low rates of insurance
coverage have set the conditions for widespread insurance fraud
in medical care. Furthermore, the forthcoming adoption of modern
information technology applied to electronic health records and
payments may accelerate the threat of insurance fraud. Fraud and
abuse take place at many points in the health care system including
doctors, hospitals, nursing homes, diagnostic facilities and pharmacies,
for example. Health care is especially susceptible to electronic
data interchange fraud. Thus, implementation of methods to identify
and prevent medical insurance fraud will help to keep health insurance
costs down and protect a patient's medical history and privacy.
[0017]As the U.S. and other countries around the world move to
modern electronic health records, the ability of criminals to steal
or otherwise misappropriate insured patient identities, and therefore,
to make fraudulent claims against the patient's insurance policies
will become an increasing threat. The efficiency of electronic information
systems vastly increases the rate at which this type of fraud can
cause monetary including damage to the patient's identity and health
record itself. The present invention uses the patient's own medical
information to protect against such fraud.
[0018]By its very nature, healthcare, and therefore electronic
health records is distributes. A modern information system for managing
health records in the U.S. will require that patients have access
to a registry of metadata that indirectly points to the locations
where their records are stored. With the invention, this registry
is stored on a smart card, a Universal Serial Bus (USB) Key, a Personal
Computer (PC), magnetic strip card, or other pervasive device. The
data could also be stored on-line in the patient's independent account
at a health record bank. Any time the patient goes to a medical
care provider for services, the medical care provider can access
some parts of this data to support the continuity of patient care.
The provider also can access the patient's identification and medical
history for billing and payment purposes.
[0019]Identity theft and stolen insurance information will become
vastly more damaging once electronic health records and payment
systems become ubiquitous. Furthermore, the large number of uninsured
in our society may cause some, out of desperation, to use counterfeit
health insurance cards or use stolen insurance information to obtain
care; thus, passing the cost of theft on to the insurance companies,
the providers and other insured patients.
[0020]Unlike fraud involving financial systems, medical insurance
fraud can take place based on the fact that individuals hold more
than one insurance policy and visits various medical care providers.
In medical fraud there is a more complex range of preventable crimes
based on use of the coded entities in a patient's health record.
The range of medical fraud that may be prevented includes: charging
the same treatment to multiple policies; charging for incompatible
treatments; using multiple policies and multiple providers to obtain
drugs that may, for example, then be sold; and identity theft across
policies.
[0021]In financial systems, one does not see data or information
being added to a particular individual's record. In other words,
the victim of fraud would not see information, i.e. money, added
to his bank or credit card account. Generally, in credit card or
bank fraud, the victim sees money removed from his account. In health
records, data may be added or removed in order to perpetuate fraud
of an individual or of a company without the victim's knowledge.
For instance, fraudulent deposition of a misdiagnosis could be used
to gain access to healthcare or medications. For example, one having
fraudulent intent could add a record that he has chronic back pain
and must be prescribed a potent pain medication. The individual
could then obtain a prescription for that medication based on the
fraudulent record one in which data has been deposited. Another
example would be someone with a diagnosis that would preclude some
sort of health benefit or treatment. In such a situation, an individual
might want to "deposit" a second diagnosis that contradicts
the first or remove the unwanted report. Thus, in health care fraud,
the complexity of the health care system makes the detection of
fraud a challenge.
[0022]FIG. 1 illustrates a flow diagram according to an embodiment
of the invention for a method of detecting and preventing medical
insurance fraud of the invention.
[0023]The method detects and prevents fraudulent medical insurance
claims by storing identifying information and medical transaction
histories on both a portable storage device and on a server (100).
The portable storage device (200 in FIG. 2) of the method may comprise,
for example a smartcard, a USB key, a magnetic strip card, a PC,
personal digital assistant (PDA), cell phone, or even an online
service owned by the patient as well as any other similar portable
device. This portable storage device comprises a registry of patient
identifying information and medical histories. The information could
be just a reference to the documents by universal resource locator
(URL). The patient identifying information and medical history also
resides on a server (202) accessible directly by the patient's portable
device, by the medical care provider or by the insurance carrier.
U.S. Pat. No. 5,832,488, incorporated herein by reference, discloses
a system and method for programming the storage of medical histories
on a storage device and a second computer. U.S. Pat. No. 5,832,488
provides a way to automatically collect data for the purposes of
providing the patient and attending physician a electronic health
record to be used in patient care. The invention described herein
takes advantage of the historical data within that record to detect
anomalies like identity theft and to prevent fraud.
[0024]The stored information and histories on the device and the
server are compiled from a plurality of sources (102). Those sources
include various medical care providers including, but not limited
to, primary care physicians, specialists, pharmacies, hospitals
and laboratories. A patient user presents the portable device to
a medical care provider at the time of receiving medical services,
medical supplies, medicines, etc. (104). When the patient presents
the portable device, the stored information and medical history
stored on the server is detected (read) (106).
[0025]The information and medical histories on the portable storage
device presented by the patient can be handled by a healthcare provider
transaction processor and validator. As shown in FIG. 3, the healthcare
provider transaction processor and validator (302) is the application
used by the provider for billing and validation of patient data.
This application runs on a PC and downloads the data from the patient's
portable device. The payor transaction processor and validator (304)
contact the payor's (insurance provider's) system to validate patient
information. The payor's side system communicates with the server
that has the patient's compiled medical history so that the information
downloaded from the portable device by the provider's validator
and the information from the server can be compared. Inconsistencies
trigger a fraud alert and payment would not be approved. The information
and medical transaction histories stored on both devices are compared
for inconsistencies or irregularities (108).
[0026]When the information on the portable device show inconsistencies
of either added or deleted data, potential medical insurance fraud
is indicated by the inconsistent data. An alert to potential fraud
is triggered on the server and/or portable device. Additionally,
the alert is also beneficial in circumstances where inconsistencies
in drug dosage are noted by detecting inconsistencies in the records,
for example. The detection of the inconsistency, in addition to
preventing fraud, alerts the medical care provider to potential
medical errors.
[0027]In circumstances were the information and medical histories
on both the portable storage device and the server are the same
or consistent with each other, the information and medical histories
on each device are updated to include the current transaction the
patient is requesting on presentation of the portable storage device.
The provider accesses the patient's information and medical history
on the portable storage device present at the time of service. The
payor matches the local history from the patient's portable device
with the history data on the server. If the information and histories
on the patient's device and the information from the server accessed
by the provider's transaction processor and validator match, the
transaction is considered valid. The provider approves the treatment
and sends a message, e.g. a bill, which updates the payor's registry
and also the server. That information is communicated to the server
and the portable device to update the patient's identifying information
and medical histories on each device. Both the provider's process
validator and the payor's process validator communicate with the
server to access the patient information and medical history because
the system may detect medical fraud even in instances where insurance
is not involved.
[0028]In an example of a fraudulent encounter, a criminal organization
or individual steals or otherwise misappropriates the patient's
identifying information and medical history or makes a counterfeit
copy of the patient's portable storage device. A copy of the patient's
device is made. The copied device is presented to a provider. The
provider accesses the patient's identifying information and medical
history from the device and the server. The provider or payor matches
the local history from the patient's portable device with the history
data on the server. Data from the copy is considered valid, so provider
approves treatment. The provider sends a message, e.g. a bill, that
updates the server and the patient's personal registry on the copied
device with a reference to the new encounter with a medical provider
for services. The data on the counterfeit device is now out of synch
with the data on the actual patient's own copy of his medical history
on his portable device. The very next time the patient sees a provider
the provider and payor system will discover the synchronization
error and inform the patient of the possible fraud. If multiple
counterfeit copies are used, the first time a single counterfeit
device is used all counterfeit devices become out of synch. Thus,
the fraud is contained to the use of the illegal counterfeit use
of a single copy of the patient's information and history from his
device. The fraud is automatically detected any time a second a
device is used. The more widespread the counterfeit, the faster
the fraud is detected with the present method.
[0029]Fraud can be detected even more quickly than described above
using direct messaging between the patient's device and the server.
With each encounter for medical services the patient can be notified
electronically of the new encounter and thus be informed on the
very first fraudulent use or billing to a health insurance policy.
[0030]The embodiments of the invention can take the form of an
entirely hardware embodiment, an entirely software embodiment or
an embodiment including both hardware and software elements. In
a preferred embodiment, the invention is implemented in software,
which includes but is not limited to firmware, resident software,
microcode, etc.
[0031]Furthermore, the embodiments of the invention can take the
form of a computer program product accessible from a computer-usable
or computer-readable medium providing program code for use by or
in connection with a computer or any instruction execution system.
For the purposes of this description, a computer-usable or computer
readable medium can be any apparatus that can comprise, store, communicate,
propagate, or transport the program for use by or in connection
with the instruction execution system, apparatus, or device.
[0032]The medium can be an electronic, magnetic, optical, electromagnetic,
infrared, or semiconductor system (or apparatus or device) or a
propagation medium. Examples of a computer-readable medium include
a semiconductor or solid state memory, magnetic tape, a removable
computer diskette, a random access memory (RAM), a read-only memory
(ROM), a rigid magnetic disk and an optical disk. Current examples
of optical disks include compact disk--read only memory (CD-ROM),
compact disk--read/write (CD-R/W) and DVD.
[0033]A data processing system suitable for storing and/or executing
program code will include at least one processor coupled directly
or indirectly to memory elements through a system bus. The memory
elements can include local memory employed during actual execution
of the program code, bulk storage, and cache memories which provide
temporary storage of at least some program code in order to reduce
the number of times code must be retrieved from bulk storage during
execution.
[0034]Input/output (I/O) devices (including but not limited to
keyboards, displays, pointing devices, etc.) can be coupled to the
system either directly or through intervening I/O controllers. Network
adapters may also be coupled to the system to enable the data processing
system to become coupled to other data processing systems or remote
printers or storage devices through intervening private or public
networks. Modems, cable modem and Ethernet cards are just a few
of the currently available types of network adapters.
[0035]A representative hardware environment for practicing the
embodiments of the invention is depicted in FIG. 2. This schematic
drawing illustrates a simplified hardware configuration of the above-described
portable storage device (200) comprising, for example, a magnetic
strip (202), a re-writable memory device (204) patent for storing
patient identifying information and medical histories, a central
processing unit (CPU) which may include a display device, computer,
etc. (206), a power supply (208), and connectors (210) to connect
the device to a reader. As would be understood by those ordinarily
skilled in the art in light of this disclosure, FIG. 2 illustrates
only one example of the portable device. The portable device could
comprise all elements of any well-known device such as a smart card,
PDA, PC, USB device, cell phone, etc., the details of which are
omitted herefrom to focus the reader on the salient aspects of the
invention. Therefore, for example, the memory 204 could comprise
any form of re-writable memory including magnetic media, hard drive,
flash memory, etc. Similarly, the CPU/display 206 can comprise any
form of processor and display from a simple logic circuit and light
emitting diodes to a system-on-a-chip with an active matrix display.
For example, see U.S. Pat. No. 6,798,647, U.S. Pat. No. 7,039,759,
and U.S. Pat. No. 7,025,277, which are incorporated herein by reference.
[0036]FIG. 3 represents a representative hardware configuration
comprising the above-described portable storage device (200), provider
transaction processor and validator (302), payor transaction processor
and validator (portable device reader) (304), and server (306).
[0037]A representative hardware environment for practicing the
embodiments of the invention is depicted in FIG. 4. This schematic
drawing illustrates a hardware configuration of an information handling/computer
system in accordance with the embodiments of the invention. The
system comprises at least one processor or central processing unit
(CPU) 10. The CPUs 10 are interconnected via system bus 12 to various
devices such as a random access memory (RAM) 14, read-only memory
(ROM) 16, and an input/output (I/O) adapter 18. The I/O adapter
18 can connect to peripheral devices, such as disk units 11 and
tape drives 13, or other program storage devices that are readable
by the system. The system can read the inventive instructions on
the program storage devices and follow these instructions to execute
the methodology of the embodiments of the invention. The system
further includes a user interface adapter 19 that connects a keyboard
15, mouse 17, speaker 24, microphone 22, and/or other user interface
devices such as a touch screen device (not shown) to the bus 12
to gather user input. Additionally, a communication adapter 20 connects
the bus 12 to a data processing network 25, and a display adapter
21 connects the bus 12 to a display device 23 which may be embodied
as an output device such as a monitor, printer, or transmitter,
for example.
[0038]The foregoing description of the specific embodiments will
so fully reveal the general nature of the invention that others
can, by applying current knowledge, readily modify and/or adapt
for various applications such specific embodiments without departing
from the generic concept, and, therefore, such adaptations and modifications
should and are intended to be comprehended within the meaning and
range of equivalents of the disclosed embodiments. It is to be understood
that the phraseology or terminology employed herein is for the purpose
of description and not of limitation. Therefore, while the embodiments
of the invention have been described in terms of preferred embodiments,
those skilled in the art will recognize that the embodiments of
the invention can be practiced with modification within the spirit
and scope of the appended claims. |