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

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

The Office of Inspector General (OIG) has posted a guide that “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.” (Note: I’ve bolded what I consider to be the key take-aways in this OIG introduction.)

This 20-page guide references 3 recent OIG reports/studies on potential abuse and neglect of Medicare and Medicaid beneficiaries. The guide provides hyperlinks to each of these 3 reports on page 3 of the guide.

The guide provides:

  • Explanation of the OIG approach when using claims data to identify incidents of potential abuse or neglect of vulnerable populations;
  • Inclusion of a flow chart showing key decision points in the process and the detailed lessons that the OIG has learned using this approach;
  • 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 and
  • Inclusion of links to OIG’s and other agencies’ reports that address abuse and neglect and links to other useful websites.

Here’s what the guide includes:

OIG Reports

All Settings Including Medical Facilities

  • Using Medicare Data to Identify Potential Abuse/Neglect: A-01-17-00513

Nursing Homes and Skilled Nursing Facilities

  • Potential Abuse/Neglect at SNFs: A-01-16-00509
  • A Few States Fall Short in Investigations: OEI-01-16-00330
  • Nursing Facility Compliance: OEI-07-13-00010
  • Adverse Events at SNFs: OEI-06-11-00370
  • Criminal Convictions of Nurses’ Aides: OEI-07-10-00422
  • California’s Unidentified and Unreported Deficiencies: A-09-09-00114
  • Nursing Home Employment of Staff with Criminal Records: OEI-07-09-00110

Group Homes

  • Alaska Group Homes: A-09-17-02006
  • Featured Topic: Group Homes
  • Joint Report on Best Practices
  • Maine Group Homes: A-01-16-00001
  • Massachusetts Group Homes: A-01-14-00008
  • Connecticut Group Homes: A-01-14-00002

Reports by Other Agencies

Nursing Homes and Skilled Nursing Facilities

  • GAO: Nursing Home Quality: GAO-18-694T
  • GAO: Nursing Home Abuse/More Can Be Done: GAO-02-312
  • GAO: Nursing Home Abuse/Shortcomings Exist: GAO-02-448T

 

Group Homes and Intermediate Care Facilities

  • CT: 10 Year Mortality Study

 

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

Key Decision Points to Help Identify Unreported Incidents of Abuse or Neglect

  • Download a flow chart of “Decision Points.”
  • Download a detailed “Lessons Learned” document that corresponds with the flow chart.

 

List of Possible Diagnosis Codes for Use During Data Mining

  • Examples of diagnosis codes used to identify potential critical incidents for our Critical Incidents Involving Medicaid Beneficiaries with Developmental Disabilities review. Download Excel Spreadsheet
  • Examples of diagnosis codes used to identify potential incidents of unreported abuse or neglect of Medicare beneficiaries being treated at SNFs. Download Excel Spreadsheet
  • Examples of diagnosis codes we used to identify potential incidents of physical and sexual abuse, rape, maltreatment, and abandonment in our Using Medicare Data to Identify Potential Abuse or Neglect review. Download Excel Spreadsheet
  • Download all diagnosis codes in one spreadsheet
  • Download all diagnosis codes in one PDF

 

Here’s just one example of one of the downloads – examples of diagnosis codes used to identify potential incidents of unreported abuse or neglect at SNFs:

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This guide and relating hyperlinks are well-worth the read as are all OIG reports. What could your diagnosis data say about your facility/community?