Fraud, Waste & Abuse Investigation Support
Advisory services related to the investigation and identification of fraud, waste & abuse
In an industry facing more complex regulations each day, healthcare entities must stay abreast of every new and revised regulation in real time. Failure to stay up to date with current billing standards hinders both a provider’s ability to produce clean claims, as well as a health plan’s ability to process payments accurately. The necessity of this task is underscored by the weekly headlines of fraud and abuse convictions and Corporate Integrity Agreements.
Altegra Health supports a zero-tolerance approach to fraud, waste and abuse management, working alongside Special Investigations Unit (SIU) staff to protect the overall integrity of the healthcare system. We assist in the development of investigative techniques to target specific areas of fraud, waste and abuse. Our team works alongside investigators to assist in detection and recovery efforts, as well as cultivating strategies for prevention pre-payment.
The intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s).
Waste is not defined in the rules, but is “generally understood to encompass overutilization, underutilization or misuse of resources, and typically is not a criminal or intentional act.” Examples of waste by a beneficiary could include making excessive office visits or accumulating more prescription medications than necessary for the treatment of specific conditions.
Waste by a provider could include ordering excessive laboratory tests such as a comprehensive metabolic panel, or group of blood tests, when only one test, such as blood urea nitrogen (BUN), is needed, or ordering magnetic resonance imaging (MRI) instead of a mammogram for preventive care.
A range of the following improper behaviors or billing practices including, but not limited to:
- Billing for a non-covered service;
- Misusing codes on the claim (i.e., the way the service is coded on the claim does not comply with national or local coding guidelines or is not billed as rendered); or
- Inappropriately allocating costs on a cost report
For more information, contact:
Melissa Scott, CHC, CPC
Director, Advisory Services Division
Office: 310.776.4500 Ext. 2370 | Cell: 951.440.4920