Common Healthcare Red Flags

The following common red flags apply to many healthcare entities. Please note that this is not an all-inclusive list and that not all of these flags will apply to all healthcare organizations.

Red Flags at registration

• Patient cannot produce a valid insurance card at the time of service, or presents an insurance number without an insurance card.
• Address listed on patient's insurance policy does not match the address on the patient's driver's license.
• Photograph on a driver's license or other photo identification card does not match the individual presenting it.
• Patient's Social Security number range does not correlate with his or her date of birth or is the same Social Security number submitted by other patients in the system.
• Patient presents documentation that appears to be altered or forged, or that gives the appearance of having been destroyed and reassembled.
• Patient refuses to provide all required personal identifying information.
• Patient provides a P.O. Box or a mail drop as a home address.
• Patient provides an address or telephone number that is the same as or similar to the address and telephone number submitted by an unusually large number of other patients.
• Patient provides personal identifying information that is inconsistent when compared against external information sources or that is associated with known fraudulent activity.

Red Flags for patients

• Patient received a bill for another patient.
• Patient received a bill or EOB for services the patient denies having or for treatment from a provider the patient did not patronize.
• Complaint or question from a patient about receiving a collection notice from a bill collector, or about information being added to their credit report by a healthcare provider or insurer.
• Patient who has a previous history of identity theft disputes a bill.

Suspicious events, patterns or activities

• Records indicate medical treatment is not consistent with physical examination or medical history.\
• Insurance claims for legitimate services are denied due to depletion of insurance benefits or because lifetime cap is reached.
• Facility or patient receives a notice or inquiry from an insurance fraud investigator.
• A new revolving credit account is used in a manner commonly associated with known fraud patterns.
• Mail sent to the customer is repeatedly returned as undeliverable, although transactions continue to be conducted in connection with the patient's account.
• An alert, notification or warning is received from a credit reporting company regarding this patient.

Mr. Hamilton (dhamilton@mnetfinancial.com) is president and CEO of Mnet Collection Agency. Mnet specializes in helping medical providers improve their cash flow and reduce their bad debts. Customers include specialty hospitals, ASCs, imaging centers and physicians. Learn more about Mnet Financial.