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

This resource guide explains our approach to using claims data to identify incidents of potential abuse or neglect of vulnerable populations. The guide synthesized the methodologies that OIG developed in our extensive work on identifying unreported critical incidents, particularly those involving potential abuse or neglect. These methodologies were used in work examining a variety of care settings, including nursing facilities and group homes. 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 tailored to their specific 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 to target which medical records should be reviewed can help identify individual incidents of unreported abuse or neglect, 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. The 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.