Healthcare Fraud Investigators provide a valuable resource in the fraud analysis process. They perform in-depth evaluation and analysis of potential fraud cases and requests for information using claims and other sources of data. One method for gathering information during an investigation is performing interviews. Along with analysis of records and other data, conducting fraud investigation…
Audit
Healthcare Secret Shopping: An Effective Tool for Detecting Fraud and Abuse
The Government Accountability Office (GAO) made headlines recently when sharing news that 11 of 12 fictitious applicants obtained coverage for health insurance through the Federal marketplace. GAO targeted the Federal marketplace with secret shopping – constructing fictitious applicants who should not have received health insurance. The secret shopping applicants provided invalid Social Security information or…
Ambulance Billing Fraud and False Claims
Medicare ambulance claims, just like everything involved with Medicare, must meet certain requirements to be considered valid ambulance transport claims. The main factor is the transport must be considered “medically necessary” under Federal Law. To do this, two specific criteria must be met: The use of other transportation methods is contraindicated by the condition of…
Electronic Health Record Challenges: A Look at EHR Fraud, Security Issues, & Adoption Barriers
Since the late 20th to early 21st century, reports such as “To Err is Human” by the Institute of Medicine have been published and have advocated the adoption of electronic health records (EHRs). EHRs offer tools to mitigate human error, be a medium to share personal medical records securely across the country, establish electronic communications…
Medicaid Dental Fraud, Waste and Abuse Reporting
OIG has just released the last in a series of four Medicaid dental fraud reports. The reports identified dentists and orthodontists with questionable billing practices in New York, Louisiana, Indiana, and California. These reports are just one part of OIG’s multi-faceted approach to combat dental fraud. The agency also has ongoing audits of Medicaid dental…
Identifying Fraud is Not Always Easy: Analyzing State Medicaid Fraud Control Unit Reports
The U.S. Department of Health and Human Services Office of Inspector General (OIG) recently released a data chart offering fiscal year (FY) 2014 statistical data for the Medicaid Fraud Control Units. For those of you unfamiliar with Medicaid Fraud Control Units (MFCU), the MFCUs are: single identifiable entities of State government that conduct a Statewide…
Medicaid Managed Care Audits Pay Off…In the Long Run
In May 2014, the Government Accountability Office (GAO) released a report calling for increased oversight of Medicaid managed care spending (the report can be found here). GAO reported that “Most state and federal program integrity officials we interviewed told us that they did not closely examine Medicaid managed care payments, but instead primarily focused their…
Improving Healthcare Error Reporting In Healthcare Audits
The purpose of this paper is to offer a technique to more clearly and fully describe healthcare errors detected in audits, which can lead to improved return on investment (ROI) for healthcare audits. A clear and complete description of all identified errors in a healthcare audit report will help assure that all readers of the…
