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Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
Health Care Fraud Hurts!
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Health Care Fraud Hurts!

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An introduction to health care fraud, how much it costs US citizens, and strategies and solutions to minimize health care fraud.

An introduction to health care fraud, how much it costs US citizens, and strategies and solutions to minimize health care fraud.

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  • 1. Health Care Fraud Hurts!<br />The Impact of Health Care Fraud, and What You Can Do<br />To Fight Fraud within Your Organization<br />February 2010<br />1<br />
  • 2. Agenda <br />2<br />
  • 3. Alpine Consulting Overview<br />Technology Practices:<br />Information Management<br />e-Commerce<br />3<br />
  • 4. 4<br />Recent Fraud Mitigation Solutions<br />Social Services Integration – “Single View”<br /><ul><li>Aggregated view of social services activity
  • 5. Fraud & abuse reporting
  • 6. Investigative support</li></ul>Medicaid Fraud<br /><ul><li>Medicaid recipient fraud
  • 7. Medicaid provider fraud
  • 8. Litigation support</li></ul>Customer Screening & Compliance<br /><ul><li>Anti-Money Laundering
  • 9. Inappropriate / Unlawful Relationships
  • 10. Suspicious Activities</li></ul>Customer Screening & Compliance<br /><ul><li>AML, BSA, Patriot Act Compliance
  • 11. Transaction aggregation & disambiguation
  • 12. Investigative support</li></ul>Loss Prevention & Risk Management<br /><ul><li>Insider threat / conflicts of interest / collusion
  • 13. Nevada State Gaming Board compliance
  • 14. Suspicious activities, customer/employee screening</li></li></ul><li>The State of Health Care in the U.S.<br />Sources: <br />Centers for Medicare & Medicaid Services (US Department of Health) “NHE Projections 2009-2010”<br />5<br />
  • 15. Medicaid Program Woes<br />State: Medicaid Deficit ($ Millions)<br />New York $ 548.1Illinois $ 379.3Ohio $ 281.2Pennsylvania $ 261.2New Jersey $ 241.9Texas $ 235.0California $ 203.6Wisconsin $ 200.0Massachusetts $ 197.0Florida $ 188.5<br />6<br />
  • 16. Ripe Environment for Fraud<br />Opportunity<br />Pressure<br />Rationalization<br />7<br />
  • 17. Fraud, Waste, and Abuse Statistics <br />Sources: <br />Coalition Against Insurance Fraud. www.insurancefraud.org.<br />8<br />
  • 18. Fraud Opportunities“Where there’s smoke, there’s fraud”<br />9<br />
  • 19. Pressure to Commit Fraud <br />10<br />
  • 20. Fraud Rationalization<br />11<br />
  • 21. Failure to fight fraud<br />12<br />
  • 22. Fighting Fraud Effectively <br />13<br />
  • 23. Alpine JumpstartGet Started with our Fraud Data Assessment<br />14<br />
  • 24. Alpine Fraud Mitigation TechnologiesUsed within the Fraud Data Assessment<br />Memento Security <br />IBM Identity Insight<br />15<br />
  • 25. Memento Security<br />16<br />
  • 26. IBM Identity Insight<br />17<br />More info at:<br />http://www-01.ibm.com/software/data/identity-insight-solutions/<br />
  • 27. 18<br />Case Study: Health Care Claims<br />A Sample “Investigative Lead”:<br />Entity #2580111<br />Providers: 70010000ZL4550<br />XXXX URGENT CARE LLC<br />XXXX URGENTCARE<br />1735 XXXXX Ste 450 Okemos, MI 48864<br />1735 Hamilton Okemos,MI 48864<br />Tax ID Number: 38203XXXX<br />HHS List: 491<br />XXXX URGENT CARE CENTER<br />1735 XXXX Ste 450 Okemos,MI 48864<br />Sanction Code: 1128a1<br />Sanction Type: Program Related Conviction<br />Sanction Date: 2005/11/20<br />Entity #3817587<br />DEA List: AG3117808<br />MELINDA SMITH<br />1735 XXXX Unit 450 Okomos,MI 48864<br />DEA Number: AG3XXXX08<br />EAS Entity #2923070<br />DEA List: BG7716333<br />AMANDA SMITH<br />1735 XXXX Rd Okemos,MI 48864<br />DEA Number: BG7XXX333<br />Gender: M<br />
  • 28. 19<br />Getting Started:Fraud Data Assessment<br />What we need from you:<br />Meet with Alpine to discuss your needs and objectives<br />Verify availability of data<br />Define the scope of the analysis<br />Execute data security and service agreements<br />Transfer data to Alpine<br />Verify initial results<br />Allocate sufficient resources to investigate leads<br />What you get:<br />Identity Insight Intelligence Report – Contains the results of your analysis (“leads”)<br />.pdf, .xls, .mdb, or other structured format.<br />Service summary – summary of findings; instructions on using the reports and tools; technical recommendations<br />Tutorial on how to use the reports/tools<br />Optional: Investigative support services<br />
  • 29. Summary:Fraud is more than a “cost of doing business”<br />20<br />
  • 30. 21<br />Q&A / Contact Information<br />Thanks! Questions?<br />Contact Info:<br />Corporate HQ: West Coast US:<br />Stan Duda Earl Stevens<br />(224) 520-7400 (702) 688-0628<br />sduda@alpineinc.comestevens@alpineinc.com<br />
  • 31. Alpine Consulting Overview<br />22<br />
  • 32. Alpine Core Solutions<br />E-Commerce<br />Portals<br />Managed Services<br />Information Management<br />Custom Development<br />User Interface Design, Usability, LAF Design, ADA, SEO, Training<br />Strategic UI<br />Application Security, Assessment and Development<br />Security<br />Accelerate ROI and extend the value of your existing IT solutions <br />IT Strategy, Technology/Application Selection, Interim IT Management<br />CIO Services<br />

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