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can healthcare fraud special investigators keep up the pace?

July 20, 2017

This week the U.S. Justice Department announced one of the biggest multi-agency healthcare fraud busts in history involving a total of 412 people, including almost 115 doctors, nurses, and other medical professionals. The alleged fraudsters were charged with defrauding Medicare, Medicaid, and TRICARE programs of $1.3 billion, billing for unneeded drugs and treatments that were often never provided.


Every single day, we read about allegations of or sentencing for healthcare fraud scams. Medicare and Medicaid programs make the big headlines, but commercial insurers feel the sting, too. 


The good news is that the industry is working together tirelessly to quell the fraud surge, as evidenced by the latest Justice Department announcement. Health plan special investigative units (SIUs) collaborate with law enforcement and government agencies to spot fraud schemes earlier and bring fraudsters to justice sooner, before they can do more damage. The bad news is that these fraud recoveries represent only a tiny percentage of the total fraud, waste, and abuse (FWA) problem while using up the bulk of a plan’s investigative resources.


So, this begs the question: Can SIUs keep up with the persistent problem of FWA? With FWA analytics identifying hundreds of providers with aberrant billing patterns daily, how do health plans with limited resources determine which are worth scrutinizing in further detail? And how do they deal with lower-dollar threshold leads beyond simply ignoring them until they grow into bigger-dollar problems? Without having the time to fully prioritize potential fraud cases, investigators will inevitably waste some time pursuing false positives or cases with little to no ROI.


We at Verscend believe that health plan SIU departments can absolutely keep up … with the help of provider network management departments and others. But doing so requires a two-pronged approach:

  • First, the delivery of "turnkey allegations," which are ready-to-investigate case referrals that have been vetted by an investigative team before the health plan SIU receives them
  • Second, a provider decision framework to understand true levels of aberrance and when and how a plan should address different categories of risk

For our take on turnkey allegations, read our white paper. And stay tuned for future blogs and perspectives on a new decision-making framework to support targeted provider interventions.


read the white paper

As director of product marketing, Warren Lesnefsky is responsible for the go-to-market planning and execution of Verscend’s Payment Accuracy solutions. He brings nearly 20 years of healthcare marketing experience in leading cross-functional teams to successfully launch information technologies and analytic services to the payer and provider markets. Prior to joining Verscend in 2015, Warren held various marketing management roles at McKesson Health Solutions with a wide range of responsibilities covering events management, marketing communications, and product marketing. He holds a BA in Marketing from the University of Northern Colorado.

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