bduchek@movebeyondcompliance.com

Tel: 800-730-2296

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Medical Insurance Companies

In 2017, the Government Accountability Office (GAO) estimated that 10% of Medicare Advantage payments ~ a whopping $16.2 Billion ~ were lost to insurance fraud, improper payments, waste, and abuse. The Centers for Medicare and Medicaid Services (CMS) and private insurers such as Aetna, Blue Cross Blue Shield, and United Health Group have very robust fraud-detection units.... so why are billions still being lost to fraud?  

 

One of the reasons for medical fraud losses is the fraud-detection life cycle, which can take a significant amount of time.  Unfortunately, from the time a provider is noticed, to the time of exclusion, up to one year can pass.  During this time the fraudster can switch cities, states, and businesses without being caught. 

A second reason why fraud losses are high may be that insurance agencies do not cross-share exclusion information. For example, if a New York doctor is excluded in Medicaid, he may move next door to NJ to open up shop, and NJ may not have this information from the NY exclusion list.  

Beyond Compliance helps prevent healthcare insurance fraud by combining several exclusion lists, such as the LEIE file, GSA-SAM suspension and debarment file, Medicaid exclusion lists, with our proprietary Health Care Fraud File, which contains very recent fraud indictments, pleadings, and convictions.  An insurance provider typically maintains a provider enrollment file, which we merge against our library of exclusions lists.  What makes Beyond Compliance unique is Health Care Fraud File (HCFF); it is updated daily with news stories on criminal indictments and arrests in the healthcare space, whether the arrest is for a doctor or an individual caught in a pill-mill scheme.  Each provider's National Provider Identifier (NPI) is attached to each arrest announcement, along with the exact URL link to the relevant article.  The majority of the news announcements are from reliable sources, such as the Department of Justice, the Office of the Inspector General, and the Federal Bureau of Investigations.  

We currently screen health care providers against the following lists:

  • our proprietary Health Care Fraud File (HCFF)

  • the OIG LEIE File

  • the System for Award Management (SAM) Exclusion List

  • the NPPES File (National Plan and Provider Enumeration System)

  • State Medicaid Exclusion Lists

  • Drug Enforcement Agency (DEA) Cases Against Doctors

  • State Medical Board License Disciplinary Actions

Using our batch matching software, we will scrub your provider file against all of our exclusion lists, to identify potential insurance fraud as efficiently as possible.  Because we make a significant effort to attach the NPI to every record, our batch matching process has a high degree of accuracy, with minimal false positives.  Our advanced fuzzy-matching algorithms allow us to find connections that may have previously been hidden, all while maintaining a low false positive rate.