Health Care Fraud Hurts!
- 1. Health Care Fraud Hurts!The Impact of Health Care Fraud, and What You Can DoTo Fight Fraud within Your OrganizationFebruary 20101
- 2. Agenda 2
- 3. Alpine Consulting OverviewTechnology Practices:Information Managemente-Commerce3
- 4. 4Recent Fraud Mitigation SolutionsSocial Services Integration Single ViewAggregated view of social services activity
- 5. Fraud & abuse reporting
- 6. Investigative supportMedicaid FraudMedicaid recipient fraud
- 8. Litigation supportCustomer Screening & ComplianceAnti-Money Laundering
- 9. Inappropriate / Unlawful Relationships
- 10. Suspicious ActivitiesCustomer Screening & ComplianceAML, BSA, Patriot Act Compliance
- 11. Transaction aggregation & disambiguation
- 12. Investigative supportLoss Prevention & Risk ManagementInsider threat / conflicts of interest / collusion
- 13. Nevada State Gaming Board compliance
- 14. Suspicious activities, customer/employee screeningThe State of Health Care in the U.S.Sources: Centers for Medicare & Medicaid Services (US Department of Health) NHE Projections 2009-20105
- 15. Medicaid Program WoesState: Medicaid Deficit ($ Millions)New York $ 548.1Illinois $ 379.3Ohio $ 281.2Pennsylvania $ 261.2New Jersey $ 241.9Texas $ 235.0California $ 203.6Wisconsin $ 200.0Massachusetts $ 197.0Florida $ 188.56
- 16. Ripe Environment for FraudOpportunityPressureRationalization7
- 17. Fraud, Waste, and Abuse Statistics Sources: Coalition Against Insurance Fraud. www.insurancefraud.org.8
- 18. Fraud OpportunitiesWhere theres smoke, theres fraud9
- 19. Pressure to Commit Fraud 10
- 21. Failure to fight fraud12
- 23. Alpine JumpstartGet Started with our Fraud Data Assessment14
- 24. Alpine Fraud Mitigation TechnologiesUsed within the Fraud Data AssessmentMemento Security IBM Identity Insight15
- 26. IBM Identity Insight17More info at:http://www-01.ibm.com/software/data/identity-insight-solutions/
- 27. 18Case Study: Health Care ClaimsA Sample Investigative Lead:Entity #2580111Providers: 70010000ZL4550XXXX URGENT CARE LLCXXXX URGENTCARE1735 XXXXX Ste 450 Okemos, MI 488641735 Hamilton Okemos,MI 48864Tax ID Number: 38203XXXXHHS List: 491XXXX URGENT CARE CENTER1735 XXXX Ste 450 Okemos,MI 48864Sanction Code: 1128a1Sanction Type: Program Related ConvictionSanction Date: 2005/11/20Entity #3817587DEA List: AG3117808MELINDA SMITH1735 XXXX Unit 450 Okomos,MI 48864DEA Number: AG3XXXX08EAS Entity #2923070DEA List: BG7716333AMANDA SMITH1735 XXXX Rd Okemos,MI 48864DEA Number: BG7XXX333Gender: M
- 28. 19Getting Started:Fraud Data AssessmentWhat we need from you:Meet with Alpine to discuss your needs and objectivesVerify availability of dataDefine the scope of the analysisExecute data security and service agreementsTransfer data to AlpineVerify initial resultsAllocate sufficient resources to investigate leadsWhat you get:Identity Insight Intelligence Report Contains the results of your analysis (leads).pdf, .xls, .mdb, or other structured format.Service summary summary of findings; instructions on using the reports and tools; technical recommendationsTutorial on how to use the reports/toolsOptional: Investigative support services
- 29. Summary:Fraud is more than a cost of doing business20
- 30. 21Q&A / Contact InformationThanks! Questions?Contact Info:Corporate HQ: West Coast US:Stan Duda Earl Stevens(224) 520-7400 (702) 688-0628sduda@alpineinc.comestevens@alpineinc.com
- 32. Alpine Core SolutionsE-CommercePortalsManaged ServicesInformation ManagementCustom DevelopmentUser Interface Design, Usability, LAF Design, ADA, SEO, TrainingStrategic UIApplication Security, Assessment and DevelopmentSecurityAccelerate ROI and extend the value of your existing IT solutions IT Strategy, Technology/Application Selection, Interim IT ManagementCIO Services