How Do Health Insurance Companies Detect Fraud?
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2 سال پیش
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Watch this video to get an answer to "how do health insurance companies detect fraud?"
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Timestamps
0:00 Intro
0:35 How Companies Detect Insurance Fraud
0:59 Detecting Fraud
1:25 Procedural Requirements To File A Fraud Case
1:54 What Happens After The Affidavit Is Filed?
2:34 After The Investigation
Video Transcript
Healthcare fraud is frequently picked up by insurers. They have compliance officers, they have their own integrity units that constantly review the work performed by those physicians and other providers who are on their panels. They’re able to compare more or less what one provider does versus another.
0:35 How Companies Detect Insurance Fraud
If you have one particular person who seems to be an outlier. Maybe this person is billing so much more than his peer group or maybe he’s focusing on some single procedure or cluster of procedures where he’s billing these over and over again at very high numbers. Frequently, insurers will pick up on those frauds.
0:59 Detecting Fraud
Now, they may even investigate those themselves. In the case of a private insurer, if it’s a Medicare supplemental policy that does the initial investigation, Medicare is by definition involved, and they may get the government involved by way of the U.S. Attorney’s office. There are very strict procedural requirements that are required to state a healthcare fraud action.
1:25 Procedural Requirements To File A Fraud Case
The relator has to file an affidavit describing the fraud. It has to be in-depth. It has to be material. The relator practically has to have an almost complete knowledge of every aspect of the fraud to state a claim in today’s world because there’s some case law out there that makes these cases even more challenging. Once the relator provides the disclosure, the matter is initially filed in the federal district court under seal where no one has access to it.
1:54 What Happens After The Affidavit Is Filed?
That occurs for at least six months, so that the government can investigate the claims. I say at least six months, under the statute it remains under seal for at least sixty days. The government can virtually never investigate these matters in sixty days, so it’s very common to request consent orders to extend the seal over a prolonged period of time.
I’ve got one fraud case now that’s been under seal since 2017, which was four plus years ago, and we’re still waiting on the government to complete their investigation.
2:34 After The Investigation
But again, it stays under seal for purposes of confidentiality and allowing the government to do an in-depth investigation. At that point, the government makes a decision as to whether they want to intervene and move forward on the case themselves or at all times, the relator has the opportunity to do it his or herself. That involves the virtual necessity of an attorney who understands healthcare fraud.
Again, find someone who’s experienced, who knows what they’re doing, and can work with you if you suspect you’ve been the victim of fraud.
At LawMD, our attorneys are not just award-winning legal professionals; most of them are also medical doctors. Our team comprises medical professionals with specialties and capacity in emergency medicine, surgery, pediatrics, radiology, dentistry, and a number of other specialties and subspecialties. We also consist of highly respected trial lawyers, seasoned negotiators, and experienced litigators. It is this winning combination of legal and medical knowledge that earns our reputation among many as the legal team with “the right medicine for justice.”
GET IN TOUCH:
Visit us ► LawMD.com
Call us ► 1-888-MY-LAWMD
Disclaimer
"Nothing in this video, or in links provided in the description of this video, constitutes legal advice or the practice of law. Nor does viewing this page form an attorney/client relationship between you and any Lawyer at LawMD. All visitors should consult with a qualified legal professional regarding their individual questions, needs, or issues that may be of concern. We are not responsible for any action taken by a reader based upon any information in this video. All of the content in this video is for general informational and educational purposes only."
Learn More ►https://www.lawmd.com/video/examples-...
Timestamps
0:00 Intro
0:35 How Companies Detect Insurance Fraud
0:59 Detecting Fraud
1:25 Procedural Requirements To File A Fraud Case
1:54 What Happens After The Affidavit Is Filed?
2:34 After The Investigation
Video Transcript
Healthcare fraud is frequently picked up by insurers. They have compliance officers, they have their own integrity units that constantly review the work performed by those physicians and other providers who are on their panels. They’re able to compare more or less what one provider does versus another.
0:35 How Companies Detect Insurance Fraud
If you have one particular person who seems to be an outlier. Maybe this person is billing so much more than his peer group or maybe he’s focusing on some single procedure or cluster of procedures where he’s billing these over and over again at very high numbers. Frequently, insurers will pick up on those frauds.
0:59 Detecting Fraud
Now, they may even investigate those themselves. In the case of a private insurer, if it’s a Medicare supplemental policy that does the initial investigation, Medicare is by definition involved, and they may get the government involved by way of the U.S. Attorney’s office. There are very strict procedural requirements that are required to state a healthcare fraud action.
1:25 Procedural Requirements To File A Fraud Case
The relator has to file an affidavit describing the fraud. It has to be in-depth. It has to be material. The relator practically has to have an almost complete knowledge of every aspect of the fraud to state a claim in today’s world because there’s some case law out there that makes these cases even more challenging. Once the relator provides the disclosure, the matter is initially filed in the federal district court under seal where no one has access to it.
1:54 What Happens After The Affidavit Is Filed?
That occurs for at least six months, so that the government can investigate the claims. I say at least six months, under the statute it remains under seal for at least sixty days. The government can virtually never investigate these matters in sixty days, so it’s very common to request consent orders to extend the seal over a prolonged period of time.
I’ve got one fraud case now that’s been under seal since 2017, which was four plus years ago, and we’re still waiting on the government to complete their investigation.
2:34 After The Investigation
But again, it stays under seal for purposes of confidentiality and allowing the government to do an in-depth investigation. At that point, the government makes a decision as to whether they want to intervene and move forward on the case themselves or at all times, the relator has the opportunity to do it his or herself. That involves the virtual necessity of an attorney who understands healthcare fraud.
Again, find someone who’s experienced, who knows what they’re doing, and can work with you if you suspect you’ve been the victim of fraud.
At LawMD, our attorneys are not just award-winning legal professionals; most of them are also medical doctors. Our team comprises medical professionals with specialties and capacity in emergency medicine, surgery, pediatrics, radiology, dentistry, and a number of other specialties and subspecialties. We also consist of highly respected trial lawyers, seasoned negotiators, and experienced litigators. It is this winning combination of legal and medical knowledge that earns our reputation among many as the legal team with “the right medicine for justice.”
GET IN TOUCH:
Visit us ► LawMD.com
Call us ► 1-888-MY-LAWMD
Disclaimer
"Nothing in this video, or in links provided in the description of this video, constitutes legal advice or the practice of law. Nor does viewing this page form an attorney/client relationship between you and any Lawyer at LawMD. All visitors should consult with a qualified legal professional regarding their individual questions, needs, or issues that may be of concern. We are not responsible for any action taken by a reader based upon any information in this video. All of the content in this video is for general informational and educational purposes only."
2 سال پیش
در تاریخ 1401/03/12 منتشر شده
است.
723
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