Download Special Report

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