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.

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Health Care Fraud Hurts!

  1. 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. 2. Agenda <br />2<br />
  3. 3. Alpine Consulting Overview<br />Technology Practices:<br />Information Management<br />e-Commerce<br />3<br />
  4. 4. 4<br />Recent Fraud Mitigation Solutions<br />Social Services Integration – “Single View”<br /><ul><li>Aggregated view of social services activity
  5. 5. Fraud & abuse reporting
  6. 6. Investigative support</li></ul>Medicaid Fraud<br /><ul><li>Medicaid recipient fraud
  7. 7. Medicaid provider fraud
  8. 8. Litigation support</li></ul>Customer Screening & Compliance<br /><ul><li>Anti-Money Laundering
  9. 9. Inappropriate / Unlawful Relationships
  10. 10. Suspicious Activities</li></ul>Customer Screening & Compliance<br /><ul><li>AML, BSA, Patriot Act Compliance
  11. 11. Transaction aggregation & disambiguation
  12. 12. Investigative support</li></ul>Loss Prevention & Risk Management<br /><ul><li>Insider threat / conflicts of interest / collusion
  13. 13. Nevada State Gaming Board compliance
  14. 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. 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. 16. Ripe Environment for Fraud<br />Opportunity<br />Pressure<br />Rationalization<br />7<br />
  17. 17. Fraud, Waste, and Abuse Statistics <br />Sources: <br />Coalition Against Insurance Fraud.<br />8<br />
  18. 18. Fraud Opportunities“Where there’s smoke, there’s fraud”<br />9<br />
  19. 19. Pressure to Commit Fraud <br />10<br />
  20. 20. Fraud Rationalization<br />11<br />
  21. 21. Failure to fight fraud<br />12<br />
  22. 22. Fighting Fraud Effectively <br />13<br />
  23. 23. Alpine JumpstartGet Started with our Fraud Data Assessment<br />14<br />
  24. 24. Alpine Fraud Mitigation TechnologiesUsed within the Fraud Data Assessment<br />Memento Security <br />IBM Identity Insight<br />15<br />
  25. 25. Memento Security<br />16<br />
  26. 26. IBM Identity Insight<br />17<br />More info at:<br /><br />
  27. 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. 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. 29. Summary:Fraud is more than a “cost of doing business”<br />20<br />
  30. 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 /><br />
  31. 31. Alpine Consulting Overview<br />22<br />
  32. 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 />