Using Health Care Audits to Detect Health Care Fraud

health care auditPreventing healthcare fraud is a very important feature of healthcare audits. Many practices, with a healthy internal audit plan, can spot issues that could result in fraud accusations. Other times, they identify fraud that may be occurring for one reason or another.

With the help of a healthcare consultant who is knowledgeable in healthcare audits, practices can get the most out of their audits. These audits can be conducted externally or consultants can help devise an internal audit procedure that can identify problems quickly so they can be rectified.

Data analysis is an important part of fraud prevention because it allows you to examine all of the critical transactions that are susceptible to fraud, abuse, and error. This is due to the fact internal control systems can have weaknesses that can be exploited. To implement an effective fraud prevention program, it is important to look at all transactions and compare their data from systems and applications to find matches that shouldn’t be there. Duplicate entries, incorrect entries, and inefficiencies are all clues that something is wrong and it can then be identified what needs to be fixed.

Preventing Healthcare Fraud

There are proven tests that are available to help detect and prevent fraud so that money can be found within the organization. Your healthcare consultant can use some of their proven tests and help you develop an internal audit plan that can help you identify issues in the future.

When it comes to excessive billing, the culprit tends to be the healthcare providers themselves. For example, a physician with the same diagnosis on the same procedure over and over; or an excessive number of procedures per day or service location, could result in excessive billings. There are cases where physicians claim to have seen so many patients in a single day that they were only able to spend a minute with a patient. This could indicate that there is some sort of abuse within the system.

There have also been cases of upcoding procedures, whether intentional or not. This is when codes for expensive procedures are submitted over and over again. When statistics are compared, this is an anomaly that becomes obvious. There are other physicians that have submitted age-inappropriate treatments. For instance, a teenager being treated for a geriatric disease could be suspect. This could indicate a billing code error.

There are even cases where fraud is committed by those claiming a healthcare expense. For instance, a person may submit claims for the same thing or they will create fraudulent family members. These are cases where individuals who claim five dependents born within a two-year period with different birthdates. This clearly shows that there is someone trying to get more people covered than just their own children or they are trying to capitalize on a healthcare benefit. There have even been cases of gender-inappropriate treatments, such as a man giving birth to a baby.

While some of this sounds absurd, it does happen and it happens often. This is why it is important to perform healthcare audits to find errors internally and to find out who else may be trying to work the system. Any time healthcare fraud occurs, it is the medical industry that pays a price. That price is eventually handed down to the patient in the form of higher healthcare costs. Getting a handle on fraud can slow down the increase in the cost of healthcare.

Creating an Internal Audit Procedure

It is good to have an external healthcare audit in order to have a fresh set of eyes identify what is happening within the practice. This can create a firm platform to build off of when creating internal audit procedures that can help ensure the integrity of the practice and its bottom line. By creating this plan, you can perform your own audits to detect issues and then correct those issues on your own. However, having your healthcare consultant do an audit for you on a schedule can help identify those issues that you might miss. Being close to the situation can make it easy to miss some items, but both types of audits are very important to ensuring the practice’s integrity, profits, and compliance with all regulations that are in place at the time.


If you are already performing internal audits or you need to, it is good to work with a healthcare consultant on setting up a solid plan, as well as have external audits performed that give you a fresh perspective. To learn about how MD Pro Solutions can help you, call 508-946-1665 or complete our contact form so someone can contact you.