Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Case Study Dr. Traveler—Recap

Case History: Dr. Traveler is a licensed MD with a philanthropic edge in providing free healthcare examinations to the underinsured. The primary healthcare continuum market players, in this case example, are defined as a licensed medical doctor, working in a free-standing clinic not affiliated with any other provider, taking care of privately insured, Medicare, and Medicaid patients. Secondary victims have been identified as a billing and collection agency. Financial damages have been assessed to exceed $2.1 million in just a one year period.

Data Highlights: Home health visits in volumes that significantly exceed the realistic number of patients per day, during prohibitive travel conditions, including the treatment of patients with his home address and of those that are deceased. Dr. Traveler submitted paper claims via U.S. mail, while a billing company and collection agency were collecting payments from the same population electronically. Further, it appears that Dr. Traveler remained under the radar of the claims adjudication system until a hotline complaint was made by a family member of a patient. At the same time, Dr. Traveler was calling attention to himself with a sudden increase in claim activity from one year to the next.