Posted and filed under Coding, Fraud, FWA.

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.

When a provider commits healthcare fraud, and they hit all the “goodies,” we just have to write about it (and do a facepalm). Take the case of this provider in New Jersey, for example. Granted, this is only a press release for a Complaint, and not a plea or sentencing, there is much to unfold. That being said, this particular provider did make us raise an eyebrow. 

He was good enough to allegedly bill while he was not in the office, primarily on out of the country trips. These types of schemes do make us shake our heads, as it is possibly one of the easiest frauds to prove. Our retired OIG agents have told us that even the newest of investigators can make a case like this. Travel records, credit card receipts, border crossings, and a host of other documents can show the entire travel pattern for the period when billings occurred and the provider was not in the office (and we know, someone will poke a hole and argue locum tenens, which is potentially true, but not likely, and even less likely in a Medicare situation). 

The impossible day is just as good. Billing for timed codes and thinking that algorithms and data analysis is not in place for the hard-working provider who does not sleep, eat or take a restroom break is just poor fraud planning. If you are not showing up in one plan billing as aberrant, a trained investigator will be pulling data from multiple payers and doing some basic math. It does not take long to calculate that there are only so many hours in a day and thus, only so many patients to be seen. 

We always take a slightly different approach in our consulting, in that our retired agents know the schemes from the inside and outside. We know the questions to ask when doing our consulting work and can address these red flags. How a provider can still think, in the age of nearly real-time information, that the schemes above are not detectable, is difficult to understand. Again, facepalm moments. 

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.