Can ICD-10 codes mask healthcare fraud?

Carl Natale
by Carl Natale
Can ICD-10 codes mask healthcare fraud?

Big data is one of the best ways to detect healthcare fraud. And since ICD-10 coding promises lots of ICD-10 data, there should be lots of opportunity to detect fraud.


Todd Fannin, director of claims for LexisNexis Risk Solutions, lists ICD-10 coding as one of the potential challenges for healthcare fraud detection:

A problem with medical provider fraud in particular, Fannin says, is that there is a lot of opportunity to hide behind numbers and coding. ICD 10 coding changes will add additional complexity to SIU investigations. The reason is that the codes are becoming much more specific. “I want to say it’s increased the number of potential codes that could be used to something like four or five times,” says Fannin.

Healthcare payers have a fairly sophisticated system to detect fraud and abuse based upon mathematical formulas that examine claims. But the formulas are based upon patterns of abuse and fraud using ICD-9 codes. Now we have new patterns developing using ICD-10 codes.

As more data is collected, new formulas will get better at detecting fraud and freeing reimbursements for legitimate medical claims. Hopefully the window of expertise that could allow more fraudulent claims to slip through will be small.