1. I managed medical malpractice claims, suits and events for individual
physicians, groups and facilities in Al Ahlia.
Auditing batches received from TPA GLOBEMED by using there I GEM
Software, taking responsibility each in every claims,
checking on the performance of doctors diagnoses,
Excessive medical services and justification of medical history. Focusing on
Hospital, Clinics, pharmacy and doctors fraud
services.
Monitoring ICD 10 CODE from providers.

3. Whether you have employer-sponsored health
insurance or you purchase your own insurance policy,
health care fraud inevitably translates into higher
premiums and out-of-pocket expenses for consumers,
as well as reduced benefits or coverage. For
employers-private and government alike-health care
fraud increases the cost of providing insurance
benefits to employees and, in turn, increases the
overall cost of doing business. For many Americans,
the increased expense resulting from fraud could
mean the difference between making health insurance
a reality or not.

4. However, financial losses caused by health care
fraud are only part of the story. Health care fraud
has a human face too. Individual victims of health
care fraud are sadly easy to find. These are
people who are exploited and subjected to
unnecessary or unsafe medical procedures. Or
whose medical records are compromised or
whose legitimate insurance information is used to
submit falsified claims.

5. The majority of health care fraud is committed
by a very small minority of dishonest health
care providers. Sadly, the actions of these
deceitful few ultimately serve to sully the
reputation of perhaps the most trusted and
respected members of our society-our
physicians

6.  What Is Medicare Abuse?
 Abuse
 describes practices that, either directly or
indirectly, result in unnecessary costs to
 the Medicare Program. Abuse includes any
practice that is not consistent with the goals
 of providing patients with services that are
medically necessary, meet professionally
 recognized standards, and priced fairly.

8.  Noted: this patients are mainly appreciating
or requesting for more services and
prescriptions that are not suppose to be
prescribed .
 Be aware that there are clinics or doctors
that they ask patient to sign on empty UCAF
or do Xerox copies of original UCAF.

9. Ministry of health should have team group
justification on variety of rules and regulations
of average clean UCAF or claims. claims
submitted by hospitals & should reviewed
manually.
charges for categories of services such as IV,
procedures, antibiotics, expensive medications,
and lab work.

10. 1) Look for prospect doctors, number of claims
daily,
2) The same doctor with repeated prescription
, diagnoses, services etc.

11. 1. Doctors, who treated whopping, say 50+ patients in a day.
2. Providers administering far higher rates of tests than others.
3. Providers costing far more, per patient basis, than others.
4. Providers with high ratio of distance patients.
5. Providers prescribing certain drugs at higher rate than others.
6. Distance between claimant’s home address and medical provider
7. Multiple medical opinions/providers
8. Changing providers for the same treatment (possibly correlated with other claim activity)
9. High number of treatments for type of injury
10. Abnormally long treatment time off for the type of injury
11. Accident severity does not correlate with severity of injury
12. Providers billing for services not provided.
13. Providers administering (more) tests and treatments or providing equipments that are not medically necessary.
14. Providers administering more expensive tests and equipments (up-coding).
15. Providers multiple-billing for services rendered.
16. Providers unbundling or billing separately for laboratory tests performed together to get higher reimbursements.
17. Providers charging more than peers for the same services.
18. Providers conducting medically unrelated procedures and services.
19. Policy holders traveling long distance for treatment which may be available nearby. (Possibly scams by bogus providers.)
20. Policy holders letting others use their healthcare cards.

12. Fraud Audit Rules: The audit rules or general check points are designed
purely based on previous experience and intuition. Audit rules are used to
check the genuineness fields like Total amount billed, Total number of
patients, Total number of patient visits, Per-patient average billing
amounts, abnormally long treatment time off for the type of injury,
Providers charging more than peers for the same services and so on.
Each application is checked against these rules, if a claimant fails to
satisfy one or more rules his/her claim will be rejected or subjected to
further scrutiny.
Fraud Prediction Scorecard: In this method we predict the probability of
fraud by using a mathematical predictive model. The model is built based
on historical data which involves fraud or non-fraud indicator along with
other explanatory elements like billed amount, number of patients,
Reporting Lags, Treatment Characteristics, Years of Experience of
doctor, Number of Prior Incidents from doctor etc.,. We use advanced
statistical techniques to find the patterns in the historical data and come
up with a predictive model. The model takes above explanatory fields
(found in claim application) as input and gives a predicted fraud score as
output.