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Best People. Best Solutions. Best Results.TM
Healthcare Fraud: What the Investigators are Investigating Ryan - - PowerPoint PPT Presentation
Healthcare Fraud: What the Investigators are Investigating Ryan - - PowerPoint PPT Presentation
Healthcare Fraud: What the Investigators are Investigating Ryan Dorsey Health Fraud Investigator- UPICW Jacob Ortiz Health Fraud Investigator Lead- UPICW February 27, 2020 Best People. Best Solutions. Best Results. TM Todays Topics
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What is the UPIC ?
- The Unified Program Integrity Contractors (UPICs).
- Perform fraud, waste, and abuse detection, deterrence
and prevention activities for Medicare and Medicaid.
- There are 5 UPIC Jurisdictions:
Western Qlarant South Western Qlarant Mid Western Advanced Med North Eastern Safeguard Services South Eastern Safeguard Services
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Investigations
- CONDUCT INTERVIEWS
- DATA ANLYSIS
- GO ONSITE
- REVIEW MEDICAL RECORDS
- APPROPRIATE ACTION
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Beneficiary Sharing
- Routine/ Scheduled billing
- Recycling between Agencies
- Related providers
- Multiple providers (40+)
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Dental Care
- Currently, Medicare will pay for dental services that are an integral part
either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw.
- Medicare will also make payment for oral examinations, but not
treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances.
Extract Year Submitted Charge Amt Allowed Amt Paid Amt Dist Claim Cnt Bene 2009 $4,659,653.16 $2,864,119.55 $2,235,339.20 11565 5339 2010 $2,689,131.25 $1,597,811.61 $1,253,271.12 6646 3615 2011 $3,557,837.26 $2,211,898.78 $1,694,063.62 10377 5104 2012 $3,289,796.29 $2,065,503.81 $1,603,137.86 8750 4204 2013 $3,847,316.46 $2,088,035.84 $1,600,799.10 7785 3755 2014 $8,232,694.20 $4,103,017.71 $3,155,999.35 9274 4128 2015 $18,260,367.73 $7,968,690.92 $6,157,992.00 11180 5374
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Home Health/ Hospice
Beneficiaries not aware of eligibility requirements No Prior Relationship/ Mobile Doctors Misleading marketing Solicitation Other Relationships
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CASE EXAMPLES
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Home Health
HHA Shared Bene's HHA 1 150 HHA 2 244
OWNERSHIP BILLER BENEFICIARIES NEW DOCTOR
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PODIATRY
Bene Cnt ICN Cnt 629 1,022 1 1 1 1 Principal Diagnosis Pain in limb Sw elling of limb Dermatophytosis of foot Provider Shared Bene's
- DR. A
933
- DR. B
812
- DR. C
1,385 Location Bene Cnt M BLVD. 27 O ST. 41 C BLVD. 10 D ST. 12 M ST. 23 S WAY 34 H ST. 14 W AVE . 11 R AVE . 22 C AVE . 16
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