Eric, Wade and Matt discuss a recent case resulting in substantial prison time and over $3M in restitution for a provider and clinic assistant who engaged in fraudulent lab test and prescription orders to the captive audience of several adult daycare centers.  These cases are sobering reminders that the predatory nature of providers can be exacerbating.  Ordering medically unnecessary medications and lab tests provides huge reimbursements, induces kickbacks (in this case the kickbacks were masked as rental agreements) and collateral fraud schemes that can result in exposing plan members to the harm of a medication that may have an adverse affect on the patient, increases costs to programs and clouds the decision making of the ordering provider.  Know your data, know your payment polices and work with collateral groups to ensure compete data is able to be synthesized.

Eric. Matt and Wade discuss two recent cases where individuals used stolen (and in one case, a repeat offender) of healthcare professionals for their own financial and other benefits. SIU plans can stay vigilant, and identify the right cases and right investigations.

Matt, Eric and Wade discuss a recently published study on podiatry claims.  This study is a rehash of a 2002 review, where as we say “same circus, different clowns” is evident.  Some of the same issues identified in the 2002 review were still present in the study capturing 2019 and 2020 data.  These studies can help an SIU shape special projects, run separate analytics for exposure and provide an understanding of policy from the CMS perspective.

Eric, Wade and Matt discuss the importance of keeping morale strong, productivity high and ensuring that investigators know that their work is relevant and matters, but sometimes things are out of their control.

Eric, Wade and Matt continue their discussion from last week’s podcast to dive a bit deeper into a few of the recommendations that remain as open items for HHS program consideration.  We look at the potential exposure to financial losses to programs from a lack of data coordination in Medicare Part A and Part D, and the implications of HCC risk scores in the Medicare Advantage space.

Eric, Wade and Matt discuss the newly released OIG unimplemented recommendations for 2025.  In total, nearly 1200 recommendations since 2017 have remained outstanding. This is part one of a two part discussion, so make sure you tune in next week as well.

Eric, Wade and Matt discuss a recent OIG study that found duplicate payments being made for certain DME products when the patient was in-patient.  This behavior permeates not only DME, but can also implicate other things such as medications.  We discuss the overall importance of having strong edits and how this type of review can greatly increase ROI, opportunity cost and reduce case backlogs by not needing to perform medical record reviews.

Eric, Wade and Matt discuss the art and science of negotiating a settlement with a provider.  Should there be dedicated investigators that only work settlement negotiations, and what are the follow ups after the settlement is completed?

Eric, Wade and Matt discuss the complexities and pros and cons of using proprietary and common off the shelf tools for SIU work.  There are strong arguments for each, and things to consider when making your decision on what tool or platform to use.

Eric and Matt have a discussion about how device and pharmaceutical firms work to market the difference in cost for the item and how the provider can make a lot of money by using the various devices and drugs to be administered.