Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation

Healthcare is inundated with rules. Coupled with high dollars and voluminous transactions, any audit or investigation would be compromised without the use of technology. Effective use of technology platforms to filter and scrutinize data is essential. The market offerings are increasing with off-the-shelf software and with private entities that are investing in proprietary platforms to synthesize data. The basics of running known “rules” against a claim file should be the baseline standard. For example, the Social Security death index should be routinely applied against a claim file. We do not provide services to deceased patients. Headlines like “Medicare paying for surgeries on dead patients?”1 illustrate the low-hanging fruit opportunities that exist. The data on deceased patients was published in a report conducted by Pearl Diver Technologies, in which they reviewed data from the CMS. The analysts found “that between 2004 and 2008, CMS paid for 142,000 procedures by 2,119 hospitals or clinics on approximately 4,980 dead patients. Eventually, CMS paid $33 million for those claims.”2

Worse yet, dead doctors do not treat patients. The New York Times published congressional testimony and noted, from the following report on dead doctors providing treatment, that, “The total amount paid for these claims is estimated to be between $60 million and $92 million. These claims contained identification ...