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 relationship via the submission of the claim itself).

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.