We dramatically decrease the expenses caused by fraud for our healthcare clients. In addition, we often discover other ways that our clients can save money. These are some of the ways we’ve saved our clients millions of dollars:

$2.5 Million Growth Hormone Fraud Ring

During a casual review of pharmacy expenditures, we noticed that our client spent far more on growth hormones than we expected. Growth hormones should be prescribed for growth hormone deficiency or AIDS wasting that has not been responsive to steroids. Neither of these legitimate uses would account for the volume of growth hormones dispensed to this client’s beneficiaries.

By linking physician and pharmacy claims, we determined that $2.5 million of growth hormones were for patients who did not have any physician claims indicating they had HIV. The pharmacy claims indicated that the drugs were prescribed by just a handful of physicians. These physicians had not submitted any claims for the patients who received the drugs.

Subsequent investigations by the client determined that fraud had occurred. The client prosecuted the cases and implemented enhanced controls to prevent further fraud.

Millions of Dollars of Highly Suspicious Prescriptions

We created metrics to identify physicians with abnormal prescribing practices. Most people go to doctors and pharmacies close to home. It is unusual for a doctor’s prescriptions to be filled at hundreds of pharmacies spread across a many counties. Our metrics identified 500 physicians who we suspected of fowl play. We recommended that investigators initially focus on 13 particularly suspect physicians who prescribed $18 million of drugs during the year. By focusing on these highly suspect providers, investigators could maximize savings.

Transportation without Other Services

We identified $700,000 of unjustified transportation expenses. By comparing claims for transportation services to other services received on the same day, we were able to find $700,000 of unjustified transportation claims in one county during a six-month period.

$1.5 Million Savings from a Very Small Change

We identified Durable Medical Equipment (DME) that should have been purchased instead of rented. The client’s policy was to purchase equipment if the patient was expected to use it for more than 10 months. We found that one type of expensive equipment was always rented instead of purchased, though it was usually used for the rest of the patient’s life. By enforcing their policy correctly, the client would save $1.5 million in the first year alone.