OIG Roundtable (Formerly Retro Fraud)

Eric and Matt discuss a recent policy disseminated by the DOJ that discusses the sub-regulatory role of policies in the government space (LCD/NCD). While these polices do not have the force of law or regulation, they are still seminal points to be relied upon from an investigative perspective.

MA plans are not required to reject claims from non-participating providers, while traditional Medicare requires providers to be enrolled in order to submit claims. This creates a huge FWA opportunity as there is no real way to vet the provider and the claims since there is no contractual relationship between the provider and payor (unless some state law or regulation establishes such a relationsh...

Eric and Matt discuss a recent case where an individual engaged in identity theft and sought healthcare benefits under the stolen identity. This case is notable as the dollar amount was fairly low in comparison to other healthcare fraud matters, but demonstrates the aggressive approach the US Attorney’s Office is taken to curb FWA.

Eric and Matt discuss the Pig and the Python and how the influx of baby boomers will have an effect on SIU operations and staffing needs.

Eric and Wade discuss a recent indictment of a medical biller who engaged in a 6-year system Medicaid fraud scheme which included false billing for behavioral health providers, billing for deceased patients, incarcerated patients and patients that were under hospital care.

Eric, Matt and Wade discuss the often overlooked need to capture the right documents in an Incident To investigation. Catch phrases in requests for documents such as “including, but not limited to” can create confusion for providers. Get what you need the first time with some of our advice.

Eric and Matt discuss a recent $46m global resolution involving the cornucopia of kickbacks: lavish gifts, cash and prizes. The pharmaceutical manufacturer resolved the matter and was not excluded. Like winning the Showcase Showdown, and getting a 4 day, 3 night stat at the NY Algonquin Hotel, sometimes fraud does pay.

Eric, Wade and Matt discuss recent work being done by UPICS as it relates to plans and audits being conducted by the UPICS of plans. This is bit of a shift from what we know the UPICS to do, but is not uncommon.

Eric and matt discuss some of the top moments in history that changed or affected the healthcare payer and payment industry. While this is only the tip of the iceberg on this topic, we look forward to keeping this discussion moving along.

Eric and Matt discuss a recent case out of the District of NJ, where a pharmacist and a pharmacy technician were involved in a broad fraud scheme that included falsifying documents in response to an audit, as well as billing for medications for the pharmacist and technician that were never dispensed and billed to their respective insurance.

Eric, Matt and special guest Dave Beachler discuss ROI from the government and the commercial plan space. ROI can be tricky and there may be some intangible factors to consider.

Eric and Matt discuss the most recent roundup, resulting in a large number of arrests, civil complaints, and the growing use of the OCIG CMP authorities to effect behavior change in the healthcare ecosystem.

Eric and Matt discuss a $30 million settlement that was predicted on several Qui Tams that were filed against a pathology lab for misrepresenting services, services not rendered and the payment of kickbacks in return for the samples to be sent.

Eric, Wade and Matt discuss a recent sentencing where the provider was sentenced to five years of probation for a $1m fraud scheme. Does that “take the wind out of the sails” of an investigator? How do you level set expectations with the C-Suite?

Eric and Matt discuss a recent default judgement case where a Nebraska based pharmacy defaulted on a civil matter, resulting in over $3m in the judgement. Everything that you know about pharmacy FWA was part of the fraud; generic substitution, billing for unfilled prescriptions, failures in inventory, you name it.

Eric and Matt discuss a recent case that was data driven. Over $46m in claims in a 7-month period, with all metrics being outside of the curve for the provider. Data is beginning to work properly in the FWA space.

Eric and Wade welcome Jean Stone to the OIG Roundtable. Jean, a fixture in Medicare and healthcare fraud, having spent 46 years with CMS in the FWA space. Jean is a force when it comes to FWA and her current work with SMP is extremely valuable.

Eric and Wade discuss a recent OIG study where ambiguity and confusion in understanding polices and billing guidance led to millions in inaccurate payments. This is not novel, and ambiguity and confusion have been the mantra for a lifetime.

Eric, Wade and Matt discuss the importance, or disregard for various certifications in the healthcare fraud, waste and abuse space.  Whether it be a CFE, AHFI, CPC, CMPA or the alphabet soup of certifications and designations, plans and the industry look at these certifications very differently.

Eric and Matt talk about the $552 million genetic testing fraud case out of the West Coast.  It seems like we are just hitting the repeat button on cases.  Telemarketing, health fairs, door-to-door, all the usual playbook things for these frauds.  Telling people they need to get the DNA swab for genetic tests (which run upwards of $10,000 in some cases) is how you make a lot of money quickly.

Eric, Matt and Wade discuss a recent press release out of Eastern District of NY where a pharmacy owner paid kickbacks to referring doctors for medically unnecessary prescriptions and masked the payments as rental agreements or salaries for the prescribing doctor’s staff.  While these cases can be difficult to investigate from the SIU perspective, there are some key data points that can be relied...