Posted and filed under Fraud, FWA, Healthcare.

The Fraud Spotlight series is a long-form examination of current fraud trends and investigative strategies from our team of retired OIG agents and expert fraud investigators. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

We hopefully are seeing the beginning of the end with COVID-19, but we will certainly not see an end to the fraud schemes out there. Fear is a great catalyst for fraudulent behavior because those intent on committing fraud will capitalize on the fears of others. 

The promise of a cure, a place in line to receive an early vaccination, and the prospect of something for nothing are all things our most vulnerable population needs to hear to want to be “all in.” The OIG regularly posts about the latest and greatest schemes to be on the lookout for. It has been revealed time and time again that vigilance needs to be higher in otherwise seemingly legitimate services that end up with fraudulent claims being submitted. 

Our retired OIG agents are in constant contact with the industry and continue to observe large areas of vulnerability in telemedicine and telehealth. The convenience of a service in the comfort of your home, lack of need to be in person so you can remain safe and healthy, and the ability to receive care quickly are definite enticements to click that connect button. As a result, the probability of a provider providing a virtual visit for a few minutes and submitting a claim to a plan for a substantial amount of time above those few minutes is higher than it should be. 

Patients receive their benefits statements, and not unlike a hospital bill, are confused and perplexed at what is on the page. When we polled our retired OIG agents who spent countless hours interviewing witnesses about their benefits statements, they were consistently reminded that the documents were confusing. Patients had secondary insurance, their copayments were waived by their provider, or a combination of things. As such, what was written on the benefit statements was of no real consequence. 

What we’re trying to say that ultimately, patients are the first line of defense against healthcare fraud outside of the billers and coders of the medical practice. If patients are unable to understand what was billed and paid for, it will go unfettered. Price transparency, negotiated rates, and all to the things that surround the costs of service, while important, are secondary to the fact that the healthcare payment system is complicated. 

Data analytics are important, but never count out good old-fashioned investigative inquiries. When working on any FWA matter, we always want the ability to interrogate and understand data, through interviews and discussions with the stakeholders, what other issues are out there. 

COVID-19 presented a host of FWA issues, and many will not fully be understood until after the fact; arrests, civil settlements, and policy/regulatory changes. Getting in front of the fraud curve is always the first step in understanding where the unscrupulous provider is heading. It is like chess, knowing where your opponent is looking to go works to your advantage. 

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact our former OIG and Fraud Investigation team by emailing info@advizehealth.com for more information on our Fraud Spotlight series.