Coordinated approach helps Kaiser Permanente root out fraud

A centralized case management system has helped multiple departments within Kaiser Permanente coordinate fraud investigations using a standardized process, according to Marita Janiga, executive director of investigations with the National Compliance, Ethics and Integrity Office at Kaiser.

In an interview with Compliance Today, a publication of the Health Care Compliance Association, Janiga explained how Kaiser developed an Internal Working Agreement (IWA) in an effort to better coordinate compliance-related investigations that involve several different internal departments. Now, a centralized system determines which department is taking the lead on certain investigations.

"Prior to the IWA, different investigations groups were bumping into each other investigating the same allegations," she told Compliance Today.

After transitioning from her 22-year career as a healthcare fraud investigator with the Office of Inspector General, Janiga was struck by the capabilities of Kaiser's fraud control analytics team. Her investigative teams work "hand in glove" with data analytics teams to identify billing outliers that often turn into leads.

Last year, Janiga led a company-wide initiative focused on medical identity fraud in an effort to heighten provider awareness, particularly among patients seeking prescription painkillers. As part of the project, investigators educated emergency department staff and created fraud alert posters of alleged medical identity theft suspects. Meanwhile, the analytics team helped investigators identify more than 40 aliases of one patient who was frequenting various emergency departments looking for narcotics.

Medical identity theft has increased 22 percent since 2013, according to the Medical Identity Fraud Alliance, and it is frequently more costly, complicated and time-consuming than credit card fraud. Experts have said that developing a network of fraud experts is often critical to improving fraud investigations, a point that Janiga highlighted as key aspect of her hiring process.

To learn more:
- here's the Compliance Today interview

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