Get 'Fierce' about fighting insurance fraud, waste and abuse

Welcome to FierceHealthPayer: AntiFraud, the newest publication from FierceMarkets, created to support fraud prevention and detection professionals in the health insurance industry.

Have you noticed that people tend to focus on the big victories in health insurance fraud investigations--the high-dollar recoveries, the successful prosecutions, the "60 Minutes" camera crew in your office--and assume that fighting fraud is a glamorous gig full of drama and intrigue?

Well, they don't see the long hours of analytical work behind the scenes, the hard slogging that makes success in this field possible. 

But we do. And we're determined to bring you information that recognizes the working realities of your role.      

As a 27-year veteran of the insurance industry, including plenty of time in the trenches of health insurance fraud investigations, let me tell you about my first big case.

There once was a radiologist who had separate provider numbers for two offices and a portable x-ray business. He routinely filed Medicare claims. But we noticed an anomoly with them: The doctor earned more in travel fees than he did for diagnostic imaging. So we dug into his data, and a multi-year investigation full of plot twists began.  

The doctor claimed payment for services never performed. He fragmented billing. He filed assigned and non-assigned claims for the same beneficiaries on the same service dates.

Primary care physicians would send patients to him for a chest X-ray, and he'd do head-to-toe ultrasounds on them besides. One beneficiary said that when he asked the radiologist why he needed so many tests, the doctor replied: "Because we don't know what's wrong with you, Henry." So Henry and his wife spent sleepless nights worrying whether or not he had cancer before learning that all he had was arthritis ... which the couple knew all along.  

This radiologist worked closely with a cluster of providers who filed questionable claims. Almost everyone who walked through the doors of their shared office building had a predictable sequence of lab tests, imaging and primary care services regardless of their health condition.   

We put the radiologist--and his cronies--on prepayment review. Based on the quality (or lack thereof) of his radiology reports, our medical staff questioned the legitimacy of his credentials. 

We worked closely with Medicare's regional office on our case, and we presented findings to the state board of medical licensure and discipline.  

Then one day the radiologist's claims stopped coming. He fled, presumably to re-start his fradulent, wasteful and abusive practices elsewhere. It's a truism in this business: fraudsters will play with whomever will pay. 

My boss saw an article in the paper years later saying this doctor was caught selling narcotics to an undercover law enforcement agent. Authorities yanked his medical license and sent him to prison.

I often think how much this doctor cost Medicare and how much chasing him cost our company. Unfortunately, cases like this aren't exceptional. Some people never straighten up and fly right, and money earmarked for good is diverted as a result.   

Much has changed for the better in health insurance over the last few decades, but fraud schemes keep threatening our programs. Criminals have become more organized, more brazen, more inventive. And they have new tools at their disposal. But so do you.                                                 

Our goal at FierceHealthPayer: AntiFraud is to bring you news and distinctions to support your casework and corporate anti-fraud strategy. Because effective fraud detection depends on awareness of fraudulent schemes in the industry and staying on top of new trends.

I know from experience that the work you do has meaning and value. May this publication serve you well. - Jane (@HealthPayer)

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