Q&A | Legal and Regulatory Compliance

Ask the Experts: Handling Patients Who Provide False Identities

Q&A | Legal and Regulatory Compliance

Ask the Experts: Handling Patients Who Provide False Identities

Are there any policies or workflow processes for handling emergency department patients who misrepresent their identities?

Are there any policies or workflow processes for handling emergency department patients who misrepresent their identities? Specifically, I am referring to patients who present in the emergency department for care and provide false information with no identification. Staff may even recognize the person, who comes back with a different name and changes other demographics slightly. When staff notice this, they merge the records. My concern is how to stop the financial and productivity losses related to these scenarios. Are hospitals taking any legal actions, such as calling the police?

Answer 1: The patients you are referring to may be seeking pain medications related to the national opioid crisis, or perhaps they have problems with alcoholism.

We always ask for IDs, so that helps manage those seeking opioid drugs. However, if patients say they don’t have IDs, they lost their wallets, or they were victims of theft, there’s not much hospital staff can do.

The hospitals that I worked with did not seek legal recourse or notify police. They formed a multi-disciplinary team, led by nurses, social workers, and physicians. They created policies or at least guidelines to follow.

If staff determined that patients might be frequent fliers, clinical personnel would try to talk to patients and intervene. They handled these situations similarly to a mild crisis intervention, but they did not refuse treatment. If patients agreed, they offered counseling and referred them to clinics or primary care physicians. 

To avoid malpractice issues, physicians always saw the patients. However, physicians typically didn’t want to be the first people to confront these patients, so nurses or social workers/case managers—depending on time of day, day of the week—would talk to these patients.

To help identify these patients, the hospital defined what was considered a “frequent flyer” (i.e., two emergency department visits for pain or other non-acute issues within two months or five or more visits per year).

Finally, it’s important to have policies for victims of abuse and to notify authorities who can help these patients.

This question was answered by: Claudia Girabelli, a retired revenue cycle consultant, and colleague of Forum Ask the Experts panel member Suzanne Lestina, vice president revenue cycle innovation, Avadyne Health, and a member of HFMA’s First Illinois Chapter.

Answer 2: I know this is a difficult problem for hospitals. First, if offenders show insurance cards, hospitals need to be careful about reporting fraudulent identities to insurance companies, including Medicare and Medicaid. In such cases, insurance companies will attempt to find offenders, who probably will not visit the hospital again after the fraud is discovered.

Repeat offenders should be reported to the police. If hospitals ignore the behavior, they are likely to become known as facilities that will tolerate identity fraud. At the same time, hospitals need to treat patients who present with false identities, even when police have been notified. One deterrent is to warn offenders that if they come back, hospital authorities will call the police.

This question was answered by: Robin A. Johnson, who has her own law firm, The Health Law Group, and a member of HFMA’s Massachusetts-Rhode Island Chapter.

Answer 3: How to deal with patients who provide false identity information may vary depending on state law, the type of facility involved, the patient’s location within the facility (ED versus clinic, for example), and other factors. Although legal implications abound and calling the police may be an option in extreme cases, the problem is more a management issue than a legal one. I am not aware of sample polices from other hospitals, but readers are encouraged to share them with the Forum if they can.

In the meantime, I recommend the compliance officer convene a meeting with legal counsel and the directors of the emergency department, health information management, and patient financial services to discuss registration work flow. In addition, because the problem is ubiquitous, reaching out to other hospitals or health systems in your area may shed some light on solutions.

This question was answered by: J. Stuart Showalter, JD, MFS, contributing editor, Legal & Regulatory Forum.

The information provided through the Forum’s Ask the Expert service does not constitute legal advice, even when the advice is provided by lawyers. You need to obtain your own legal counsel for legal advice, and consider the laws and regulations that govern your state. The content and opinions expressed are those of the Forum experts, and not that of their employers or of HFMA. HFMA does not endorse the material or warrant or guarantee its accuracy. The responses are based only on the specific facts or circumstances provided. Forum experts cannot be held liable for outcomes related to any information provided.

Pose another question to our Legal & Regulatory Forum experts.

Sign up for a free guest account and get access to five free articles every month.


Related Articles | Legal and Regulatory Compliance

Column | Healthcare Reform

Two infrastructure bills have significant implications for healthcare and bipartisanship

Congress’ handling of two mammoth bills may well determine the political tone in Washington and whether there will be any room for bipartisanship for the remainder of President Joe Biden’s term.

How To | Cost Effectiveness of Health

Financial Sustainability Report: June 2021

This June issue of the Financial Sustainability Report, sponsored by Kaufman Hall, leads off with results of HFMA’s recent report examining the evolving role of the healthcare CFO over the next decade. Two features also examine steps health systems can take to promote success with value-based payment initiatives, including developing models to inform their efforts with risk-based contracts and focusing efforts on removing impediments to success under such contracts.

News | Coronavirus

Healthcare News of Note: Trump administration diverted nearly $10 billion in funds slated for hospitals to Operation Warp Speed

Healthcare News of Note for healthcare finance professionals is a roundup of recent news articles, including the discovery that provider funds were used for Warp Speed operations, the need to retain the Medicare telehealth expansion and healthcare antitrust issues to watch.

How To | Cost Effectiveness of Health

Financial Sustainability Report: February 2021

The February Financial Sustainability Report, sponsored by Kaufman Hall, explores emerging issues pertaining to physicians, including physician compensation and payment for services. It also includes insight into the impact of denials on value-based payment.