Top 10 procedure code analysis for special investigators

July 15, 2016

In today’s fast paced, data-driven world of auto-casualty claims there is a simple tool that can help insurance investigators uncover trends in medical treatment while identifying future investigative needs – an analysis of the top 10 professional medical services billed for auto casualty claims.

At times, investigating medical fraud and abuse can feel like searching for a needle in a haystack, with thousands of possible unique medical services being rendered to claimants on a daily basis. However, when we take the time to analyze and understand the top 10 medical services encountered by auto-casualty claimants we quickly realize the majority of injuries experienced in these claims lend themselves to a small, select number of medical services. Analysis of the top 10 medical procedures, based on total recommended dollar amount allowed for auto casualty claims, reveals that, on a national level, the top 10 professional service procedure codes billed in 2014 accounted for 48 percent of the total recommended dollar amount allowance associated with all professional medical services for auto casualty claims.

Another way of looking at this is that, for nearly half of all auto casualty claim payments for professional services, those billed on a CMS1500 can be attributed to 10 medical service codes. Taking this one step further, when we look at the top 10 procedure codes on a state by state basis, we discover that these medical services contribute as little as 33 percent (NY) to the total recommended dollar amount allowance, while in other states they are responsible for as much as 68 percent (OR). The map below demonstrates the percentage contribution made by the top 10 procedure codes to the state’s total recommended dollar amount allowance for auto casualty claims. States identified in ‘red’ demonstrate a higher percent contribution to total recommended allowance, therefore less medical service diversity.

By limiting investigation and analysis to the top 10 procedure codes, the investigator is not overwhelmed by a vast dataset, with potentially many false positive findings or dead-end leads that delay appropriate conclusions; rather they are left with a clearer picture of the medical community’s treatments of choice and how these services are driving results in that particular state. Mapping this high-level snapshot of the top 10 procedure codes contribution to total allowed dollar amount for each state of jurisdiction starts to paint a picture whereby patterns raise questions or focus resources charged with mitigating fraud and abuse.

The analysis of the top 10 professional medical codes would not only be useful for a claim special investigations unit trying to identify new directions to pursue while investigating fraud and/or buildup – it would also be invaluable to the development of training material for other front line claim units responsible for making appropriate referrals to investigators. The top 10 analysis provides valuable insight into a state’s medical community, while also helping to describe the state’s societal beliefs regarding medical treatment and alternative healthcare provider acceptance, by identifying its most prevalent services. Understanding that nearly 70 percent of all professional medical services associated with auto casualty claims in Oregon are due to 10 procedure codes might allow the claim investigative unit to focus more on these 10 codes or attempt to explain why similar accidents in different jurisdictions result in significantly different treatment plans and outcomes.

If you happen to be responsible for a state where the top 10 analysis finds little diversity of medical treatment – meaning the majority of medical claim cost is attributable to 10 medical services – investigators can focus on becoming well versed in these ten procedure codes so they understand of the codes’ appropriate use in medically necessary care, improve statement-taking skills, and bolster confidence while speaking to medical providers. If on the other hand the investigator is in a state with a very diverse medical offering of medical services, one might start by simply asking, “why?”

“To an investigator, the top 10 procedure codes should be considered the first lead on a case like a muddy footprint or a fingerprint that is trying to tell a story,” states Michele Hibbert-Iacobacci, Vice President, Information Management & Support, Mitchell International.

Let’s consider the diversity of medical services offered by the New York medical provider community. With the top 10 procedure codes in New York only accounting for 33 percent of the total dollar amount allowed, many additional procedure codes would need to be added to the New York list of medical services to match the 68 percent in Oregon. In New York we would need to look at the top 75 procedure codes to account for 68 percent of total dollar amount allowed.

With this level of diversity comes interesting insight.  If we look strictly at the top 10 procedure codes in New York and compare them with every top 10 list from the other 49 states we discover that two procedure codes appear in New York’s top 10 that do not appear in any other state’s top 10.

If we try to determine how these two nerve-conduction velocity test procedures made it into the New York top 10 list, we might start by looking at unit cost for each service and compare it to the other 49 states. If we do this, we would find New York in the middle of the pack with respect to unit cost for procedure code 95904. However, if we look further, and analyze the cost per date of service for these procedure codes, we find that New York led the pack with the highest average allowance per date of service for both of
these codes in 2014. In order to achieve the highest rate of allowance per date of service we might surmise, and the data would support us, that the medical providers are billing for more units of service for each patient encounter. On average, New York providers rendering code 95904 for services billed three times as many units of service than the national average, while those rendering code 95903 for services billed two times as many units of service than the national average.

Ten little procedure codes trying to tell a story to investigators, just like the muddy footprint or fingerprint does. It is important for special investigators to become familiar with top 10 procedure code analysis so they might uncover leads they were otherwise unaware of, or allow them to focus on specific aspects of medical care, affording them the opportunity to become as expert in terminology and use of the services as those they are speaking with. As a result, investigators may become more accurate and efficient in their handling of auto casualty claims.