Category: FraudNews

Another fraudster in South Florida is not a big surprise. But there are two interesting things of note with this situation:

1. He is arrested! As noted in prior posts, it is often the case the fraud goes unprosecuted, but that is not the case here.
2. He probably could have been caught much earlier if software were running that was looking for repetitive behavior. Look at this aspect of what happened.

One paragraph was cut and pasted into 122 “progress notes” submitted to Blue Cross by Citrin, according to police. Here is that paragraph:

“Chief Complaints, New/Follow-up Patient Consult: “Patient c/o runny nose, fatigue. Suffered with allergy symptoms for over six months, episodes worsen during the middle of the year. During the episodes the patient has not used anything to improve. Patient has a history of smoking no pets at current residence was living in a group home and suspects black mold, takes OTC meds during episodes which usually are minimally effective, is not currently having an episode. Patient has relevant medical health condition of polysubstance dependence which causes symptoms which at times of substance withdrawal (runny nose) are overlaid on his allergy symptoms.”

With work this sloppy, there probably were all kinds of other repetitive things in the CPT codes that would have been easily flagged for review by good software.

For example, we have algorithms that read all medical bill lines, and aggregate them up by provider, claim, etc. Our algorithms are searching for all types of repetitive and/or erratic behavior.

Most insurance execs think they have something like this already installed, but when they question their technicians they realize that their software is 1) “repricing” the bills, so that they comply with a fee schedule, 2) alerting the bill coders to any single bill that has characteristics they want to review. Most software is NOT looking for suspicious behavior across bills, doctors, claims, etc.

As this article shows, if a fraudulent clinic realizes that a particular bill makes it through the system on a fast track basis, it is not unusual for the fraudster to produce the same bill over and over again, and it is not unusual for the claims system to pay it over and over again.

Here is the article.

We keep track of medical articles like that here, and PIP articles that, typically are similar, here.