Prosecution is key to fraud prevention

When it comes to fraud prevention and detection, Health Care Services Corp. (HCSC) takes a hard line against criminals.

"Our goal is to prosecute fraudsters," Sharon Green, senior manager of special investigations for HCSC-owned Blue Cross Blue Shield plans in Illinois, New Mexico, Oklahoma and Texas, told FierceHealthPayer. "Stealing healthcare is the same as stealing any other assets," she said, and criminals should be punished accordingly. 

Green likened HCSC's penchant for prosecution to cops policing the roads for speeding cars. When you know that police are ticketing speeders, you don't speed. Prosecuting people who defraud its health plans is "a very effective way to deter fraud," she said.

In fact, HCSC calculates that its 2011 fraud-related savings and recoveries was $19 million, including 11 convictions in 11 separate cases. "Return on investment isn't what we're in business for [but] we do get substantial recoveries," Robert Walsh, vice president of HCSC special investigations, told FierceHealthPayer.

HCSC was involved in the investigation and prosecution of Arun Sharma, a physician who was sentenced in 2011 to 15 years in prison for fraudulently billing some HCSC-owned health plans, as well as Medicare and Medicaid, for medical procedures he didn't perform. The feds seized $43 million in assets--HCSC recouped $8 million of that.

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"Stealing healthcare is the same as stealing any other assets."

--Sharon Green, senior manager of special investigations for HCSC-owned Blue Cross Blue Shield plans in Illinois, New Mexico, Oklahoma and Texas
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But before they can prosecute suspects such as Sharma, HCSC first must identify potential fraudulent activity. That starts with its special investigations unit (SIU), which is staffed with former law enforcement officers, medical professionals such as registered nurses, dentists and doctors, as well as former insurance execs and data-mining experts. "We have various skills working together," Green said.

The team identifies potential fraud using data-mining software that identifies outliers such as high claims amounts or claims with unusual services and from other sources, such as members' calls to its fraud hotline. The SIU team takes aggressive and fast action--if a review warrants further investigation, a manager opens a case and an investigator lays out a detailed plan of action. The team might review medical records, identify patients to interview and check for other complaints on the same provider or practice.

The key is to move quickly in order to collect as much information as possible before anyone alerts the suspects, Green said. Sometimes the HCSC SIU team will conduct as many as 15 patient interviews in one day to prevent tipping their hand.

The SIU team then contacts local police or the FBI, who can subpoena their extensive records on the alleged fraudulent activity to begin building a prosecutory case. Often, HCSC SIU's former law enforcement officers will accompany the police on interviews and participate closely as they pursue the case.

"We identify fraud and hopefully they prosecute," Walsh said.

One reason HCSC has been successful at detecting healthcare fraud is the organization's ability to scout out new scams.

"Crooks are always thinking about how to take advantage, looking for weaknesses and system vulnerabilities," Green said. "Our people think like a crook and have a tendency to be suspicious."

For even more payer strategies for preventing and detecting fraud, including advice from the FBI Health Care Fraud Squad, download FierceHealthPayer's free eBook, Payer Strategies to Prevent & Detect Fraud

Click here to view Part 2: WellPoint combats fraud with diverse anti-fraud team

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