A Resource Guide for Using Diagnosis Codes in Health Insurance Claims To Help Identify Unreported Abuse or Neglect

Report (A-01-19-00502) | Download the Complete Guide

Why Did OIG Create the Guide

Decades of Office of Inspector General (OIG) work has uncovered widespread problems in providing safe, high-quality care and reporting problems when they occur. Much of this work has focused on abuse and neglect of Medicare and Medicaid beneficiaries. This work has shown that Medicare and Medicaid beneficiaries are being treated for injuries in hospital emergency rooms that may be the result of abuse or neglect, and these events are not always reported as required. It has also shown that claims data can be used to identify critical incidents involving Medicaid beneficiaries in group homes and nursing homes. Our work has also demonstrated that health insurance claims submitted to programs such as Medicare and Medicaid can be used to identify thousands of beneficiaries who are the victims of abuse or neglect. OIG most recently identified and reported on potential abuse and neglect in the audit reports CMS Could Use Medicare Data To Identify Instances of Potential Abuse or Neglect (A-01-17-00513), Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated (A-01-16-00509), and Alaska Did Not Fully Comply With Federal and State Requirements for Critical Incidents Involving Medicaid Beneficiaries With Developmental Disabilities (A-09-17-02006). These audit reports identified tens of thousands of Medicare and Medicaid beneficiaries who were potentially victims of abuse or neglect. Some of these beneficiaries were subjected to incidents of severe abuse or neglect, such as physical and sexual assault. These beneficiaries were identified by using analytical techniques on Medicare and Medicaid claims data.

Because we have consistently found that many incidents of potential abuse or neglect are not reported, oversight and enforcement authorities are not always able to pursue legal, administrative, or other appropriate remedies to protect the health, safety, and rights of program beneficiaries. OIG has developed an approach that uses the medical diagnosis codes included in Medicare and Medicaid claims data to target medical records for review. In many of our reports, we found our methodology to be an effective approach to help address unreported abuse and neglect. For example, the CMS Could Use Medicare Data to Identify Instances of Potential Abuse or Neglect report identified more than 30,000 Medicare claims that explicitly indicated potential abuse or neglect. We found that almost 30 percent of those incidents had not been reported to law enforcement.

OIG created this guide because we are committed to supporting our public and private sector partners in their efforts to curtail this ongoing problem. Those partners include State Medicaid Fraud Control Units, Survey Agencies, Adult and Child Protective Service Agencies, as well as compliance and risk management officials working at insurance providers, hospitals, nursing homes, and group homes. These partners can use this guide to develop their own unique processes for analyzing claims data to help identify (1) unreported instances of abuse or neglect, (2) beneficiaries or patients who may require immediate intervention to ensure their safety, (3) providers exhibiting patterns of abuse or neglect, and (4) instances in which providers did not comply with mandatory-reporting requirements.

What Does the Guide Include?

This guide explains our approach when using claims data to identify incidents of potential abuse or neglect of vulnerable populations. The guide is based on the methodology that OIG developed in our extensive work on identifying unreported critical incidents, particularly those involving potential abuse or neglect.

The guide includes a flow chart showing key decision points in the process and the detailed lessons that the OIG has learned using this approach. We encourage our public and private sector partners to use this guide to develop a process unique to their circumstances and apply it to any vulnerable population they deem appropriate. The source of the data could include Medicaid Management Information Systems claims data, private payor insurance claims data, or similar data sets. Analyzing the data allowed us to select medical records that helped identify individual incidents of unreported abuse or neglect and patterns and trends of abuse or neglect involving specific providers, beneficiaries, or patients who may require immediate intervention to protect their health, safety, and rights.

This guide also provides technical information, such as examples of medical diagnosis codes, to support our public and private sector partners with analyzing their own claims data to help combat abuse and neglect. In addition, this guide includes links to OIG's and other agencies' reports that address abuse and neglect and links to other useful websites.

How To Conduct Data Mining To Detect Incidents of Potential Abuse or Neglect

Notice

The Office of Inspector General (OIG) is providing this resource guide to assist users in analyzing claims data to identify and combat instances of potential abuse and neglect. This resource guide was prepared as a technical resource and is not intended to, and does not, create any rights, privileges, or benefits, substantive or procedural, enforceable by a party against the United States; its agencies or instrumentalities; its officers or employees; or any other person. The resource guide is provided in "as-is" condition, and OIG and its employees, agents, and staff disclaim any express or implied representation, warranty, or guarantee, including, but not limited to, the implied warranties of merchantability and fitness for a particular purpose. In particular, no representation is made that the information included in the resource guide, or any data the resource guide produces, is error free. The resource guide should not be used as the sole basis to determine whether an individual had been abused or neglected, or if any provider or other individual has abused or neglected another individual. The resource guide is not intended to be used as the sole determining factor of compliance with any laws, regulations or other guidance. In no event shall OIG or its employees, agents, or staff be liable for any claim, damages, or liability, whether in an action of contract, tort or otherwise, and including direct, indirect, incidental, special, exemplary, or consequential damages, however caused, and on any theory of liability, arising in any way out of the use of this resource guide, even if advised of the possibility of such damage.