Hospital
Trace Reports as featured in PI MAGAZINE
The
Secret to Proving Insurance Fraud
By Kellie Snider
Need a way to
help your clients prove insurance fraud? There’s a little known secret weapon
available to the skilled professional investigator: hospital trace reports.
Insurance fraud
is big business. Thanks to the estimated one hundred twenty billion dollars per
year in fraudulent claims, each policy holder in the U.S. pays approximately one
hundred seventy-eight dollars per year in higher premiums.1 Fraud can be a crime
of opportunity by a party who sees a way to make a lot of easy bucks. It can
happen when physicians file claims for services they did not render. It happens
when car accidents are staged for profit, when someone exaggerates the
seriousness of an injury, or even by insurance agents who don’t submit all the
premiums they collect.
Hospital trace reports are one way to research a claimant’s background to
determine if the claim is legitimate. These reports are a search of admissions
and billing records in hospitals, clinics and other facilities offering medical
treatment within a certain geographical radius of the claimant’s home and work.
Some private investigators will also trace the area around previous residences.
Using billing and admissions information, an investigator assembles a report
indicating whether a person has received inpatient, outpatient or emergency room
treatment at any of the facilities in the given areas. The location, nature and
dates of the treatment are also included. These reports might include from eight
to twenty-three facilities.
Insurance companies, and their legal counsel, are the primary clients for these
reports. Clients can potentially save huge sums by uncovering fraudulent claims
prior to finalizing payments or settlements. These reports can also be used in
death and disability cases, and in probate cases showing due diligence to
finalize wills. They can be used to help locate missing persons who might be ill
and institutionalized. Or, they could be used to show that a prescription drug
abuse problem existed, by listing proof of duplicate prescriptions being filled
in various places for the same individual.
Hospital trace reports have been around for more than seven years according to
Deborah Rose, PI, and owner of Investigative Service Group Unlimited (ISGU).
Rose says that access to such information varies on a hospital-to-hospital
basis, rather than a legal or state-to-state basis. Hospitals all have different
policies about the release of such information. Some hospitals will release
admissions and billing information even without direct authorization.
How much
information can a PI obtain about previous medical care that might affect the
outcome of a claim? Through the tracking of Social Security numbers, date of
birth, AKAs, and prior addresses, a PI can often hit pay dirt. The more
information provided by the client, the better. ISGU also requests two signed
original search authorizations from the insurance company, employer, or other
client requesting the search. Some hospitals require a signed original before
permitting the search, so Rose recommends having it available prior to
contacting any hospitals.
To make these
reports profitable, Rose advised, it is helpful if the clients request them for
each case. Rose says that one of her clients requests a hospital trace report
for every claim she gets. On average about two of each ten reports pays off,
according to Rose. Eight will uncover no other injuries and little else of
benefit to the case. One may provide some additional information that she did
not already have, while one provides a big pay-off, often saving her client more
than $200,000.
The physical act of conducting the search also varies from hospital to hospital,
Rose warns. It is beneficial, if not essential, to have a working knowledge of
medical terms and verbiage. ISGU keeps a medical paralegal on staff to do record
collections and hospital trace report activities. Rose says the process will
fail without a working knowledge of medical terminology and the policies and
procedures of a given institution.
It may take repeated contacts to get accurate information, par for the course in
the life of a PI. Some hospitals will restrict access to information through the
billing department, but the investigator can get it through the admissions
department, so the first time one works a particular hospital, it may be
necessary to attempt to gain access through several different channels before
finding out what works within their policies. Some facilities have specific
restrictions and will only release information on the presentation of a subpoena
or the permission of the claimant. Also, some hospital personnel may be more
willing to cooperate than others.
Creating a good working relationship with the hospital personnel is always a
wise investment, Rose said. She offered the following tips:
- Don’t be
either too reserved or too aggressive in your demeanor, but at the same time
let them know that what you’re doing is important. Let them know that you
respect their jobs and their responsibilities.
- Ask
specifically what needs to be done to get the needed information. Don’t barrel
in, demanding records, or they will immediately become suspicious. They may
even deny information that might normally be provided.
- During the
entire search process, it is essential to keep accurate records of who was
contacted, how helpful they were, phone numbers, dates, times, the names and
contact information of those people who have the authority to release
information, and what is required by the facility in order to release
information. Keep this in a database that is updated each time a facility is
contacted. This will save time and aggravation later.
Rose reports that
the typical hospital trace reports including, on average, ten to sixteen medical
facilities, are usually billed out at an average of $159.00.
1Data Chek
Systems, P.O. Box 10162 Greensboro, NC 27404-0162, (336)288-3655,
fax(509)472-9856 or (336)288-3933
Kellie Snider is
a freelance writer from Dallas, TX. She wrote "Ground Penetrating Radar" for our
October 2002 issue. See Kellie’s website at: www.kelliesnider.com.
Editor’s Note: PI
Magazine cautions readers to be fully aware of all regulations - state and
federal privacy laws and FCRA, in particular - that might affect investigation
for a hospital trace report.
|