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

Today’s Topics  Investigations  Dental  No Prior Relationship  Beneficiary Sharing  Home Health/ Hospice  Case Examples

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: South Mid Western Western Western Advanced Qlarant Qlarant Med South Eastern North Eastern Safeguard Services Safeguard Services

Investigations  CONDUCT INTERVIEWS  DATA ANLYSIS  GO ONSITE  REVIEW MEDICAL RECORDS  APPROPRIATE ACTION

Beneficiary Sharing  Routine/ Scheduled billing  Recycling between Agencies  Related providers  Multiple providers (40+)

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 Submitted Dist Cnt Year Charge Amt Allowed Amt Paid Amt Claim 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

Home Health/ Hospice  Beneficiaries not aware of eligibility requirements  No Prior Relationship/ Mobile Doctors  Misleading marketing  Solicitation  Other Relationships

CASE EXAMPLES

Home Health  OWNERSHIP Shared HHA  BILLER Bene's HHA 1 150  BENEFICIARIES HHA 2 244  NEW DOCTOR

PODIATRY Location Bene Cnt M BLVD. 27 O ST. 41 Shared C BLVD. 10 Principal Diagnosis Bene Cnt ICN Cnt Provider Bene's D ST. 12 Pain in limb 629 1,022 DR. A 933 M ST. 23 Sw elling of limb 1 1 DR. B 812 S WAY 34 Dermatophytosis of foot 1 1 DR. C 1,385 H ST. 14 W AVE . 11 R AVE . 22 C AVE . 16

Questions? Ryan Dorsey Health Fraud Investigator, UPICW 562.263.2421 dorseyry@qlarant.com See risks. Solve problems. Seize opportunities. Jacob Ortiz Health Fraud Investigator Lead, UPICW 562.263.5285 Ortizj@Qlarant.com