Rules Based Post-payment Analysis allows you to look for known fraud patterns, so you can focus your investigations on the claims most likely to be fraudulent. These systems are also known as Expert Systems, because they are built based on information provided by fraud experts. The systems produce reports that identify providers, patients and claims that fit specific criteria. Each report identifies a particular kind of fraud.
Here’s an example of rules-based analysis:
Providers who order chest x-rays for all patients with respiratory distress.
Sound familiar? This problem has been in the news before. It was exposed by ABC Primetime Live in March 2004. Now Blue Cross and Blue Shield plans have filed a civil lawsuit accusing clinics in Southern California of using runners to recruit many employees from a single workplace to received over-priced and unnecessary services in return for cash.
In this issue:
- Database giant gives access to fake firms (MSNBC)
- HUNTERDON COUNTY, NJ WOMAN PLEADS GUILTY
- West Virginia Prescription Drug Ring Broken Up (WBNSTV)
- Abuses Endangered Veterans in Cancer Drug Experiments
- 5 Cases Settled in West Virginia
- NJ Pharmaceutical Company Employees Sentenced to Prison for Selling Drug Samples
- MyRxForLess Owners Guilty of Importing Phony Phamaceuticals from Mexico
- 3 Plead Guilty in $2 M Scheme to Steal Insulin From the Army
- Former pharmacist pleads guilty to felonies
- EAST BAY PHYSICIAN INDICTED FOR HEALTH CARE AND MAIL FRAUD
U.S. Attorney E. Thomas Johnston announced plea agreements of five healthcare fraud cases.
The article describes the settlements with five providers:
- Dr. William C. Dressler of Martinsburg, WV was charged with upcoding.
- Dr. Sadtha Surattanont of Romney, WV agreed to settle charges of upcoding by paying $195,000 and agreeing to five years of monitoring of his participation in Medicaid and Medicare.
- Dr. Harry D. Price of Martinsburg, WV allegedly filed false claims from 1997 to 2002.
In this issue:
- Robin’s Fraud Control Toolbox: GIS
Robin’s Fraud Control Toolbox: GIS
Geographic Information Systems can be used to dramatically decrease fraud. It can be a great tool to help you: identify geographic areas to focus on, illustrate that fraud occurred, and identify participants in fraud rings.
While we’ve talked about GIS for years, it is currently underutilized as a fraud and abuse detection tool. I think one reason it is not used more is that we are intimidated. But we don’t need to be. We aren’t preparing academic papers, so we don’t have to be perfect. We just need to be able to use the tools well enough to be able to spot potential abuses.
However, these doctors were double-paid for many services. If their patients noticed this, shouldn’t the doctors have noticed as well?
“Investigators believe that at least $10 million has been drained from a system whose costs are already harming our economy.” Insurance Commissioner John Garamendi
William Origel, Rebecca Benedict, and Robin Barney were charged with felony counts of insurance fraud, grand theft, and practicing medicine without certification. Origel is the owner of Med-1 Medical Center, P.C., and Unique Healthcare Management, Inc. Origel, with help from Bendict and Barney allegedly over-billed workers’ compensation and auto insurance carriers for services never rendered, services not medically necessary, and for services beyond the scope of their licensed authority to perform.
In this issue:
- Serono Offered Trips to France
- Home Health Owners Arrested in Spain Receive Jail Sentence
- United Health Insurance Settles DME Case
Serono Offered Trips to France
Adam Stupak, pleaded guilty on December 21, 2004 to offering three New York City doctors free trips to France if they agreed to write 30 new prescriptions for Serostim in one week. The illegal promotion was part of Serono’s “$6m-6 Day Plan” to increase demand for Serostim, an expensive drug used in the treatment of AIDS wasting.