WellPoint combats fraud with diverse anti-fraud team

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One of the most important steps that WellPoint takes to combat healthcare fraud is assembling a strong, experienced team of employees with backgrounds in various law enforcement areas, which then can be leveraged to help ensure criminals are prosecuted.

"Healthcare fraud is a pervasive issue so you need different methods of addressing it," Lee Arian, staff vice president of WellPoint's special investigative unit (SIU), told FierceHealthPayer. Among the "comprehensive nature of our efforts," he said, WellPoint's most important anti-fraud approach has been the hiring of "high-level, strong quality personnel to be involved in the fraud program."

Ten years ago, WellPoint's SIU department consisted mostly of claims processors and, although their knowledge of the claims process is critical to WellPoint's fraud prevention efforts, a successful SIU team needs to be more diverse. "We changed the paradigm to bring in professional investigators," Arian said, adding that decision was the "biggest, most effective effort we've undertaken" to combat fraud.

WellPoint's SIU team now includes people with previous experience working for the FBI, local law enforcement agencies and state insurance departments, for example. "This is a pretty well-rounded group of people on our team," Arian said.

That breadth of experience is crucial to helping investigators analyze new potential fraud cases like a district attorney or FBI agent would, including considering whether the existing facts demonstrate that fraudulent activity actually took place.

Essentially, the team determines whether they can make a fraud case and whether there's a prosecutor who will take on the case. "Because of our past skills, we're in a good position to make that call," Gary Auer, WellPoint's SIU director for California, Nevada and Colorado, told FierceHealthPayer.

The wide and varied law enforcement background of the SIU team members also helps WellPoint maintain close ties with enforcement agencies. "We leverage all the relationships folks have with the agencies where they used to work," Arian said.

For example, WellPoint is the only private insurer with a "systematic program" in place to provide information to local and federal agencies regarding the increasingly prevalent trend of doctors overprescribing painkillers like Oxycontin, the insurer said. Because the overprescribing of these drugs is "so pervasive and harmful to society," one WellPoint SIU investigator does nothing but gather information related to painkiller prescriptions and regularly distribute it to law enforcement agencies, including the FBI, as well as district attorney and sheriff offices, Auer explained.

WellPoint's main goal, however, isn't just to "put doctors behind bars," Auer said. Instead, it strives to achieve a "deterrent effect" on future fraudulent activity. "We want to make an impact on the problem for society," he added.

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