OIG Roundtable (Formerly Retro Fraud)

Eric. Matt and Wade discuss a recent news article that highlighted a 2022 OIG study on double payments in Medicaid.  Medicaid does not share date with other states, which could lead to people who move being covered in two different states.  This is a huge weakness, one that was identified by the OIG in 2022, and apparently remains an open item.

Eric, Wade and Matt discuss the complexities of conducting these investigations. While some of the investigative steps that law enforcement can do are not available to the SIU community, there are some ways for an SIU investigator to get behind the curtain and find the beneficial owner of a shell company.

Eric, Wade and Matt discuss the implications of NCD, LCD and regulations promulgated by CMS to the commercial payor space.

Eric, Wade and Matt discuss the evolving fraud scheme of causing payors to shift EFT payments to fraudsters. An evolving scheme that can be prevented.

Eric, Wade and Matt discuss how using visualization tools for data and investigations can increase efficiency, produce intangible ROI and allow collaboration in a more seamless environment.

Eric, Wade and Matt discuss the ongoing use of the terms Fraud, Waste and Abuse, and how SIU teams should not be bogged down by these terms. Do your cases and they will land in one of these categories.

Eric, Wade and Matt discuss the collateral effects of layoffs. As we are seeing in the government space, it is not so different in the commercial space.

Eric, Wade and Matt discuss the recent case out of Arizona where $1.2 billion in skin grafting kits were fraudulently reimbursed.  The case highlights the ongoing need for investigative and data vigilance to ensure payments are proper and accurate

Eric, Wade and Matt discuss the uptick in cases involving the prosecution of providers who rely upon unlicensed or unqualified individuals to render items, services and procedures to unsuspecting patients. This, coupled with the use of excluded providers is a huge compliance concern and we provide some investigative tips for success.

Eric, Wade and Matt continue the discussion from last week's podcast on provider abrasion, with a focus on investigative planning and when to use probe sampling opposed to statistical sampling.