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Special Report ABO/Rh Testing, Antibody Screening, and Biometric Technology as Tools to Combat Insurance Fraud: An Example and Discussion Eleanor K. Jator, PhD, MLS(ASCP)CM 1*, Kimily Hughley, MLS(ASCP)CM 2 In 2012, more than 47 million Americans lacked health insurance1; this is a serious problem because everyone will need access to healthcare at certain times in their lives. The main reason for lack of health insurance before the passing of the Patient Protection and Affordable Care Act (PPACA) in the United States has been reported to be affordability.1 In March 2010, the Patient Protection and Affordable Care Act was signed into law. The PPACA was especially enacted to reduce the number of uninsured Americans by providing affordable, quality health insurance and to curb healthcare spending.2 Reducing the number of uninsured is to be accomplished by expanding public (Medicaid) and private insurance as well as making health insurance more affordable by providing subsidies to eligible applicants, instituting mandates, providing tax credits and insurance exchanges.2 The Medicaid expansion clause is optional for states and as a result, some states choose not to expand eligibility. The PPACA law has a provision for a health insurance market place, which has allowed uninsured individuals, along with those who purchased their own insurance to compare and buy health insurance DOI: 10.1309/LMIEC52ZF7RLLURK Keywords health insurance, healthcare fraud, ABO/Rh types, antibody screening, biometric technology Abbreviations ID, identification; HIPAA, Health Insurance Portability and Accountability Act of 1996 1 Medical Technology Program, Austin Peay State University, Clarksville, TN and 2Medical laboratory, Diley Ridge Medical Center Canal, Winchester, OH *To whom correspondence should be addressed. E-mail: [email protected] www.labmedicine.com at affordable premiums with the help of subsidies.3 The law calls for insurance companies to accept all applicants regardless of any pre-existing conditions or gender and eliminates annual or lifetime caps on healthcare benefits. In addition, Members’ coverage cannot be terminated due to illness. All these provisions allow for addition as well as retention of individuals with health insurance coverage.2 Individuals living in states that have expanded Medicaid eligibility and have incomes below the poverty level are more likely to obtain health insurance coverage through Medicaid.3 Even with the relative affordability of health insurance, some individuals will not still purchase health insurance for various reasons. States that do not expand Medicaid eligibility will have more uninsured non-elderly adults because they have incomes that are above Medicaid eligibility criteria and these incomes are below poverty level.3 In this case, it is highly likely that these individuals may not be able to afford coverage because they will not be eligible for the financial subsidies as well as Medicaid.3 It is projected that there will be 27 million uninsured individuals by 2016, which is about 30 million4 less than the 47 million uninsured in 2012.1 There is still a potential for health insurance fraud with several millions remaining uninsured, hence the need for adequate identity verification. Along with the difficulties triggered by lack of health insurance coverage comes health insurance fraud, which was reported to be on the rise.5 Health insurance fraud often manifests in the form of identity theft, in which an individual obtains someone else’s personal data and receives health care billed to that person’s insurance without that person’s knowledge. In other cases, someone receives health care by assuming the identity of an insured person with the knowledge and permission of that person. Hence, there is a need for effective policies and procedures to track patients at each stage of their treatment. The health Winter 2014 | Volume 45, Number 1 Lab Medicine e3 Special Report care field has been slowly embracing biometric technology, which has proven to be instrumental in deterring individuals from committing fraud. We describe an example of an insurance fraud case in which an uninsured individual planned and almost succeeded in obtaining total knee replacement surgery by assuming the identity of an insured individual. Due to the limited ABO/Rh knowledge on the part of both parties, however, investigators were able to foil the attempted fraudulent actions. ABO/Rh Testing Laboratory professionals use ABO blood types, which were discovered in the early 20th century, for pretransfusion compatibility testing. ABO and Rh tests are the most common tests performed as part of hospital transfusion services and in donor centers. As many individuals outside the health care field are aware, in transfusion practice, group-specific units of blood are sequestered for patients with compatible blood types. However, most of those individuals probably do not know about other alloantibodies that have the potential to destroy transfused cells. Before an elective operation, physicians order pretransfusion compatibility work-ups on their patients. The basic panel of tests includes ABO/Rh typing and an antibody screen. If the results of antibody screen are negative, blood products are issued only if the patient eventually needs it. If the results of antibody screen are positive, antibody identification is performed in order to provide antigen-negative, crossmatch-compatible units of red blood cells for the patient. Most individuals outside the health care field assume that a donor and a recipient can receive blood from each other if their ABO and Rh types are compatible. As described in the following case, an insured individual in a hospital setting indirectly expressed this perception through her actions. Case Scenario After claiming to have exhausted every alternative form of pain management, a patient with diabetes requested a total knee replacement. A week before the elective surgery, the patient’s physician ordered pretransfusion tests. The laboratory performed a blood-type test and an antibody screen. This patient was determined to be O positive with e4 Lab Medicine Winter 2014 | Volume 45, Number 1 a negative antibody screen. On the day this patient was scheduled for her operation, the physician ordered preoperative blood work which was ordered and collected per hospital policy. This hospital’s policy on surgical procedures required a final check of ABO/Rh and antibody screening to be performed on all patients if those tests had been performed more than 72 hours earlier. This patient did not provide a photographic identification (ID) card to the registration clerk; she claimed to have left it at home. After she explained that she had received care at that hospital in the past, she was then instructed to type in her social security number on a keypad; the clerk then took her picture. The clerk then placed a wristband on the woman and directed her to the waiting area for surgery. After hospital staff performed another ABO/Rh check and antibody screening on the day of the scheduled operation, the patient’s blood type was verified to be O positive, as before; however, the results of her antibody screen were positive. This finding was very strange because the results for this patient from one week earlier were negative for unexpected antibodies. According to her medical records, this patient had not received a transfusion or organ transplant in the past 3 months. She had 2 adult children and no history of a recent pregnancy. The laboratory notified the surgical unit’s nursing staff of the possible discrepancy and that further testing would be required. The nurse who was notified informed the surgeon, who decided that the operation should be rescheduled. A different blood bank technologist repeated all tests to ensure that no testing errors had been made. The results of the antibody screen were again positive. The technologist performed an antibody identification procedure, which identified anti-K, an antibody that reacts at the anti–human globulin phase, in the patient’s plasma. The blood bank supervisor asked the nurse whether the patient had received care at another hospital after the anti-K was identified. The nurse stated that the patient had told her that she had not obtained any medical care since her most recent preoperative visit to the hospital, which had taken place 1 week earlier. Because the blood bank stores all specimens for 10 days per laboratory policy, another blood-bank technologist obtained the patient’s specimen that had been collected from the previous week and performed blood typing and antibody screening on it, to compare those results with the previous results on file. This technologist performed the test-tube (manual) method and gel technology to verify the patient’s antibody results. The antibody screen result was negative; www.labmedicine.com Special Report this was in agreement with the result from one week earlier. Two different specimens from the same patient, collected one week apart, with no health or medication changes on the part of the patient, had yielded different antibody screen results. This finding is an anomaly because anti-K is one of the antibodies that require a Kantigen negative individual to be exposed to the antigen through transfusion, transplantation, or pregnancy. Because none of these possibilities was true of this patient, the laboratory findings presented a clinical dilemma. A nurse unit coordinator informed the patient that to reschedule her surgery, another blood sample had to be collected because of a discrepancy with her laboratory results. The phlebotomist followed the venipuncture protocol; she remarked that the patient seemed oblivious to what was happening and did not seem to be concerned about the discrepancy. The phlebotomist stated that this patient was very cooperative during the second venipuncture. The nurse unit coordinator requested more information about this patient because of the discrepancy. At some point in the conversation, the patient confessed to the unit coordinator that she was in need of a total knee replacement and explained that she had no health insurance. She explained that she assumed that because her friend had the same blood type, O positive, she could safely undergo the operation in her friend’s name and have the procedure covered by her friend’s insurance policy. The patient also admitted that the only medically related visit her friend had made was for the original laboratory tests (which had yielded negative antibody-screening results) and payment of her deductible. It was later discovered that the first visit was the only time that a form of photo ID had been presented during the entire process. This incident led to the hospital requiring patients to present a photo ID during registration and to implement a procedure of scanning a barcode on patient wristbands before patients could receive any care or treatment, to prevent such a situation from happening again. Consequences of MedicalInsurance Fraud Medical-insurance fraud affects all sectors in the healthcare industry. The Ponemon Institute, an independent research organization, in its third annual report on medical identity theft, explained that the economic impact of medical identity theft in the United States was valued at $41.3 billion annually.5 The organization projected that the cost of fraud will increase further if adequate measures are not www.labmedicine.com taken to curb it. Using a median sample value, in 2011, the economic impact of medical identity theft in the United States was $7.8 billion; in 2012, that figure rose to $11.5 billion.5 The case described herein is just one of many incidents that have occurred over the years because of lack of health insurance; it is possible that many other cases have gone unidentified. The sometimes huge direct and indirect financial consequences of such cases include wasted staff time in investigating alleged fraudulent activities; labor costs; phlebotomy costs; repeat-testing costs; administrative costs; and hidden costs, including the costs of supplies, specimen processing, accessioning, and telephone calls. In such cases, productive time is squandered in making multiple investigative phone calls and questioning the patient. In this case, in addition to the costs associated with uncovering the fraudulent actions, the cancellation of the operation led to loss of revenue for the hospital and the surgeon. The consequences for the victim of medical identity fraud can also be enormous: the victim may be eventually treated based on an incorrect diagnosis as a result of false information in his or her medical history. False diagnosis also potentially renders the victem ineligible to purchase life insurance. The credit score of victims can also be affected and victims lose the time it takes to correct inaccuracies in their medical histories. Medical insurance fraud affects everyone. Fraud triggered higher premiums leading to insurance companies passing on to policyholders the costs of reimbursing huge claims and for combating attempted fraudulent actions. A new PPACA provision requires insurance companies to spend 80-85% of premiums received on medical care and imposes tougher control on premium increases.2 With more oversight and accountability, the rate of premium increases associated with fraud may be kept under control; however, policyholders will still cover costs associated with fraud. Recommendations Many healthcare facilities are in the process of adopting or have already adopted biometrics technology to cut back on health insurance fraud. This technology helps facilities to authenticate patient identity, to verify the identity of the health care personnel working on patient records, to safeguard privacy, to increase efficiency Winter 2014 | Volume 45, Number 1 Lab Medicine e5 Special Report in registering patients, to prevent creation of multiple medical records for patients, and to reduce waste of resources.6-8 Biometric technology in healthcare involves using human characteristics such as the patterns of the iris, fingerprints, palm prints, and facial features to identify patients.9,10 Biometrics has also been defined as “automated measurements of the physiological or behavioral characteristics of a living human [being] to identify and authenticate the person’s identity.”6 The healthcare industry is slowly welcoming this type of technology, which has been used for years in other industries. For example, financial institutions use biometric technology to protect customer data and to lessen costs associated with repeated password changes; retailers use it to track returns, thereby curbing financial losses. Also, biometrics applications have been used at security checkpoints of national borders and multiple entrances to Disney World, as well as in the military.11,12 The push for implementation of electronic health records and privacy protection for health records has considerably influenced the healthcare industry to embrace technologies that provide patient authentication and protect patient privacy. Possible reasons that an increasing number of healthcare organizations are using biometrics applications include compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and prevention of data compromise, medical identity theft, and medical identity fraud.6 Some healthcare organizations now require patients to present a photo ID and they check patient demographic information as well as use barcoded wristbands that must be scanned as patients travel throughout treatment areas. The use of biometrics applications and other identification options increases the levels of security and patient authentication.6 During a patient’s first visit to a healthcare facility, the facility gathers and stores his or her personal information, such as name, home address, data from health-insurance card, and a scanned record of the biometric traits used at that facility for identification purposes. On second and subsequent visits or encounters during the same visit, the scan obtained by the facility pulls up the information stored in the patient database. For example, when the iris pattern is used as the defining biometric trait, a camera reads this pattern, which is unique to the particular patient. The biometric template recorded is then connected to the patient’s electronic medical record. A medical clinic located in a high-poverty area in the Bronx, NY uses iris scans to correctly identify its patients; e6 Lab Medicine Winter 2014 | Volume 45, Number 1 the clinic’s chief medical officer believes that authentication technology will prevent the problem of mistaken identities that could occur as a result of many of their patients having the same names; in the past, this facility has had 4 to 5 medical records on the same patient. Administrators believe that, as well as preventing duplicate records, iris scans will help to reduce medical fraud.13 Some blood banks have also implemented the fingerprint biometric technology to enroll donors and to retrieve their information during visits for subsequent donations. The biometric recordkeeping systems at these facilities save fingerprint templates and personal information during the first encounter of the donor with blood bank staff. Administrative processing for individuals giving subsequent donations will involve a simple fingerprint scan that will retrieve the donor’s records.14 Because biometric technology is slowly evolving, more sophisticated features will be able to combine two types of physical traits, such as facial features and iris patterns, to enable patient identification. This will especially be helpful in cases in which a patient has deformities.12 Conclusion In the case discussed herein, the blood bank played a huge role in uncovering the fraudulent activity of 2 patients. Only discovery of an unexpected antibody result was required for the scheduled operation to be cancelled. After this incident, the hospital changed its patient identification policy by requiring that patients present a photo ID during registration, before receiving any care. The hospital also instituted a new policy warranting that the barcoded wristband placed on each patient be scanned in all treatment areas before care is received. Clinics and hospitals that have implemented biometric technology have reported a decrease in attempted and successful patient impersonation. Memorial Hospital Miramar, a Florida hospital that has implemented palm scanning, has experienced a reduction in the number of patients trying to obtain care using someone else’s identity and insurance information.10 If the hospital in the case described herein had had this technology in place, the patient attempting to impersonate her friend would not have been authenticated to undergo the scheduled operation because the patient’s biometric template would not have been linked to the friend’s electronic health record. www.labmedicine.com Special Report The healthcare industry will need to be more vigilant to spot the types of fraudulent activities described herein and to have processes or policies in place on how to detect and prevent them in all patient care departments. The use of biometrics technology is becoming popular and is used by increasing numbers of hospitals, clinics, and physician offices. Technology that verifies patient identity prevents treatment of the wrong patient, thereby helping to cut back on health care costs by lessening the possibility of medical identity fraud. The use of biometric applications along with other demographic information can greatly enhance efforts to authentication the identity of patients. LM References 1. The Henry J. Kaiser Family Foundation. Key facts about the uninsured population. Available at:http://kff.org/uninsured/fact-sheet/ key-facts-about-the-uninsured-population/. Accessed December 5, 2013. 2. ObamaCare facts: Facts on the Affordable Care Act. Available at http://obamacarefacts.com/obamacare-facts.php. Accessed December 15, 2013. 3. The Henry J. Kaiser Family Foundation. The coverage Gap: uninsured poor adults in states that do not expand Medicaid. Available at:http:// kff.org/health-reform/issue-brief/thecoverage-gap-uninsured-pooradults-in-states-that-do-not-expand-medicaid. Accessed December 14, 2013. 4. Pecquet J. CBO:Obama’s health law to cost less, cover fewer people than first thought. The Hill. Available at http://the hill.com/blogs/ healthwatch/health-reform-implementation/215795-cbo-healthlaw-to-cost-less-cover-fewer-people-than-first-thought.Accessed December 14, 2013 6. Brown, CL. Health-care data protection and biometric authentication policies: comparative culture and technology acceptance in China and in the United States. Rev Pol Res. 2012;29(1):141-159. 7. Health Management Technology. Biometric technology verifies patients’ identity. 2010 Health Management Technology. Available at:http://www.healthmgttech.com/articles/201003/biometrictechnology-verifies-patients-identity.php. Accessed December 5, 2013. 8. Scarfo P.Achieving assured authentication in the digital age. Biometric Technol Today. 2013;2013(9):9-11. 9. Herman B. Eye of the beholder:How iris biometrics could help solve hospital ID problems. Becker’s Hospital Review Web site. Available at: http://www.beckershospital.com/healthcare-healthcareinformation-technology/eye-of-the-beholder. Accessed December 5, 2013. 10.East G. Hospitals embrace high tech security. Biometrics speed admissions and reduce mistakes while cutting fraud and ID theft. Sun Sentinel Web site. Available format:http://articles.sun-sentinel. com/2011-09-07/health/fl-high-tech-patients-20110903_1_memorialhospital-miramar-patient-tax-assisted-hospital-district. Accessed December 5, 2013. 11. Greene L. Hospitals jump on the biometrics bandwagon with patient hand scans. Tampa Bay Times Web site. Available at:http://www. tampabay.com/news/health/ medicine/hospitals-jump-on-thebiometrics-bandwagon-with-patient-hand-scans/848594. Accessed December 5, 2013. 12.Trader J. Why healthcare should evaluate biometrics for patient identification. Porter Research Web site. Available at:http://www. porterresearch.com/Resource_Center/Blog_News/Blog/2012/ September/Why_Healthcare_should_Evaluate_Biometrics_for_ Patient_Identification. Accessed December 5, 2013. 13.Park M. At Bronx clinic, eyes are the windows to medical records. Cable News Network (CNN)Web site. Available at:http://www. cnn.com/2010/HEALTH/03/15/bronx.clinic.iris.scan/index. html?iref=allsearch. Accessed December 5, 2013. 14.More J. Biometric tools edge into healthcare. iHealthBeatWeb site. Available at:http://www.ihealthbeat.org/insight/2013/biometric-toolsedge-into-health-care. Accessed December 6, 2013. 5. Ponemon Institute. Third annual survey on medical identify theft. Available at: http://medidfraud.org/2013-survey-on-medical-identitytheft/. Accessed December 5, 2013. www.labmedicine.com Winter 2014 | Volume 45, Number 1 Lab Medicine e7