The days of going in and finding a lone provider doing a little up-coding are starting to go away as many of those are easily found and now we have the offices that have guns and more to protect their “up-coding” millionaire businesses.   HHS has done some good work in creating their “Most Wanted” list which again fits right in with this story and the “organized” efforts that occur with fraud. 
HHS Creates 'Most Wanted' List Website for Healthcare Fraud - Office of the Inspector General

The video below shows how they are prepared for the bust and are practicing with guns ahead of the confrontation.  The government is now using technology with formulas to identify patterns which they did not have before and this is a huge help to point HHS OIG in the right direction. 

Medicare Federal Investigators Getting Algorithms to Analyze And Find Fraud-Good Move as Contractors Efforts Are Weak With Risking Loss Of Transaction Revenue

Office of Inspector General to Monitor Upgrade of CMS Computer and Data Systems and Stimulus Incentives for EHRs

In addition with use of such software then can also identify situations like this…and get the money in sooner from insurers. 

Insurers Made $450 Million with Interest Income by Holding Medicare Funds for Around 46 Days Before Releasing Payment

Back on track here you can see how this is becoming a big business and the crooks feed on the web to find doctors credentials and NPI numbers to bill to as well.  Criminals do a better job as many don’t practice healthcare, they just bill fraudulently. 

Medicare Fraud – Criminals Do a Better Job With Filing Claims And Coding Than Providers

Anyway, the video is a good look at how fraud is beginning to shape into the world of “organized crime” and some of the battles are fought exactly in that style.  The above link has a couple additional videos of interest on the same topic to include an interview with one who was caught and talked about how he functioned.    In the meantime we seem to keep chasing the hospitals for a lot of the “billing mistakes” made by consulting companies who promise a bigger percentage return and you have to wonder there as well about the software and the consultants.  It’s usually not the clinical help as they are there to take care of patients but rather the administrative areas that are responsible for the administration and costs who find their way into some of these snags.  BD

It is one of the biggest and most overlooked factors in the rising cost of health care. According to government estimates, fraud in programs like Medicare and Medicaid costs taxpayers $80 billion a year, with some estimates as high as twice that amount.
A federal fraud crackdown, some of it mandated by the Affordable Care Act, has made a dent in the problem, but the record $4.1 billion recovered in 2011 is a small fraction of the total.

Every procedure and diagnosis has a billing code. The codes are used not only for billing Medicare and Medicaid, but in many private insurance programs as well. There are already thousands of codes, used in increasingly sophisticated data analysis by authorities seeking to spot fraud.

One such business is operated by Dr. Adam Alpers, an osteopathic physician in Ocala, FL. Alpers created a video series called "Medical Coding Cash Secrets," which he sells on his web site.


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