Ah, push it
Ah, push it
Ooh, baby, baby, baby, baby
Ooh, baby, baby, ba-baby, baby…

If you read that and thought about Salt-N-Pepa, you get a point for the day. If you thought about The 50th Anniversary of Hip Hop, you get two points. It’s a very special time for Hip Hop fans, New Yorkers, and everyone because this promises to be “the most epic year in Hip Hop history! Celebrations will be held all around the world to uplift and honor every aspect of Hip Hop culture. From concerts and tours to battles, competitions, and exhibitions, all of your favorite DJs, MCs, Breakdancers, Beatboxers, Graffiti artists, and more will show up and show out to make this golden anniversary of Hip Hop culture the most extraordinary year yet.”

Now, let’s transition to the topic of healthcare fraud:

Peppering. A client of ours asked if we knew the term “peppering.” So now we ask you, healthcare fraud fighters: Do you know the term “peppering?”

Our client went on to explain that his team has been looking for doctors peppering claims.

Scheme: Peppering
Scenario: Patients authorized for 10 visits but only go for 3. Before the billing cycle is over, the provider bills for a phantom 7 dates of service that never happened.

How to Catch It:

  • Look at the number of claims per member and watch for trending.
  • Pay attention to end-of-cycle billing and peppering in older claims.
  • Behavioral trending is key.

Here’s an example:

Lymphedema treatment: Patient Cheryl goes to Dr. Denton for insurance-approved 15 sessions of lymphedema treatment. Patient Cheryl receives 4 treatments in the first two weeks of the total approved cycle (6 months). Dr. Denton bills for services as they happen during the first two weeks. Right before the 6 months is up, Dr. Denton bills for 11 more treatments for random dates.

How to spot it in the data:

Overall trending data and patient-specific data are your best friends. Use this data to make timing comparisons. This might require collaboration between different teams, including billing and coding experts. If you spot an instance where the patient shows up for a number of repeat services, then disappears and then reappears, there has to be a reason.

How to investigate:

Contacting the patient is crucial. The patient’s input can provide valuable insights, especially if there was a break in the timing of dates of service. Collaborate with experts and consider technologies like geolocation for timestamping. For example, if a patient doesn’t geolocate themselves when they arrive and the provider bills for a phantom service, technology can help identify such discrepancies when claims are submitted.

By Jeanmarie Loria