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Detecting Healthcare Vendor Fraud Using Data
Analysis
April 17, 2013
Special Guest Presenter:Katrina Kiselinchev, CIA, CPA, CFE, CFF
This webinar and its material are the property of AuditNet® and FraudAware®. Unauthorized usage or recording of this webinar or any of its material is strictly forbidden. We will be recording the webinar and you will be provided access to that recording within five business days after the webinar. Downloading or otherwise duplicating the webinar recording is expressly prohibited.
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Vendor Fraud SchemesReminding Yourself What Exists
Bid Rigging – A commercial contract is promised to one party even though for the sake of appearance several other parties involved.
Price Fixing ‐ agreement between participants on the same side in a market to buy or sell a product, service, or commodity only at a fixed price to control pricing.
Market Division ‐ Competitors divide markets among themselves. In such schemes, competing firms allocate specific customers or types of customers, products, or territories among themselves.
Vendor Masking ‐ tricks e.g. shell companies to hide their true identity.
Inside Job ‐ current or former employees collude with vendor to approve and/or pay overstated or false invoices for personal gain.
False Claims – billing for more expensive equipment and billing for supplies never received
Bribery – involves bribes either directly or indirectly e.g. masking through classification type in order to gain service / business. Corruption PerceptionIndexes are good source for countries.
Kickbacks – typically external sources provide kickback for selection of services e.g. kickback.
Vendor Fraud SchemesReminding Yourself What Exists
Flying Under the Radar ‐ criminals avoid detection by using “proven”
techniques for blending in with legitimate invoices, vendors and payments.
Organized Crime Billing Schemes ‐ Sophisticated groups of criminals take a savvy, organized approach to defrauding your company. Medicare Examples of Increased Fictitious Companies
IMA Bleeding Co. gets an employee tip that they should look at two vendors that recently got approved for Medicare Billing. The tipster states there is massive overbilling going on for non‐eligible expenses.
“Concerns about Unnecessary Diagnostic Tests & Kickbacks”
1) Complete Summary of Data & Findingsa) Total by Each Type of Discrepancyb) Aggregate Discrepancy
2) Determine Additional Tests to Run & Perform3) Discuss Findings with Owner Initially & Recommendations4) Complete Interviews with Employees 5) Review Gaps & Control Deficiencies & Provide Recommendations 6) Recommend Management Review for Cost v Benefit & Implement ASAP7) Determine if Client has Fraud Insurance Rider. If not, recommend.8) Contact Insurance Carrier (if applicable) & Begin Claim Process.9) Contact Authorities & File Report.10) Determine if Prosecution is Viable e.g. Dollar Amount, Management, etc.11) Complete Report (See ACFE.com) 12) Complete Supporting Doc for Insurance Co. & Authorities
The Obama Administration’s bonus system for insurers participating in Medicare Advantage, the private‐market alternative to the government’s traditional health insurance program for the elderly, has been criticized
by Republicans as a political giveaway and by the Government Accountability Office as illegal.
The government rates every Advantage plan from one to five stars, depending on how they perform on a range of tests including measures of patient care, what proportion of members receive flu shots, and
measures of customer satisfaction such as complaints to Medicare. More stars are better.
Since 2011, when the bonuses first became available, the average star rating for plans that offer drug coverage — the most popular type — has
Which of the following is/are Red Flag(s)/ Finding(s) Identified in IMA Bleeding?
A. Improper Depreciation CalculatedB. No Match On Patient 125, Duplicates, Budget & Pricing OveragesC. Terminated Employees Receiving PaychecksD. No Match on Patient 125 Only