Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Anomaly and Profilers

This is a general activity for ongoing data surveillance in which no known issue exists. View the overall EDA activity within this concept as the general review of any exceptional activities, regardless of how minor they may appear to be. Trend the exceptions that are similar in scope. Apply the profiler checklist. Determine whether any of the exceptions impact any financial activity. Also, this process should incorporate the tracking of employee complaints as well as patient complaints. One approach to evaluating a complaint is to pull the respective pipeline associated with it.

A recent example is a complaint from a beneficiary. The beneficiary stated that the pharmacy sometimes sent his spouse’s prescription in the beneficiary’s name; other times the pharmacy sent it in the spouse’s name. The beneficiary also complained that regardless of who received the medication quantity for one person (spouse or beneficiary), both spouse and beneficiary were charged for the prescription. This prompted the following audit protocol:

Why would both parties be charged for the medication when only one delivery was made?

What is the implication of a pharmacy ever dispensing a medication to a party without having a prescription?

How much is the benefit plan actually paying ...