Fraud, Waste & Abuse / Special Investigations

Leads reach you from everywhere and in no particular order. A rules-based outlier report lands on a schedule and names providers whose billing sits outside their peer group. A claims processor sends over something that looked wrong. A member calls about an explanation of benefits listing a visit that never happened. A hotline tip arrives with no detail and no name attached. A state fraud bureau or another plan flags a provider you also pay. And pre-payment review sends over what an edit could not resolve, because a claim edit is not an investigation. You sort what is worth an investigator's time, and the sorting is the job. You look at billing patterns over time rather than at single claims: codes that shifted upward as a group, units that do not fit the service, modifiers appearing on nearly everything, a place of service that does not match the work, a rendering provider whose day would not hold the hours billed under it, members who turn up at unrelated providers in the same sequence. The hard part is that being unusual is not being wrong. The provider at the top of the report might have the sickest panel in the county, or be the only one in it doing the procedure at all, or have a coding habit that is incorrect and entirely sincere. And you have more leads than investigators, so the ranking you produce decides what gets looked at this year and what does not.

A lead becomes a case when someone has to prove it. You pull the subject's full claim history and every adjudication decision behind it, request records for the dates you intend to rely on, and read what the documentation says against what was billed, date by date. You look for the note that does not mention the service, the time-based code with no time recorded, the identical note appearing across unrelated members, the signature that is not there. You interview: the member who can say whether the visit happened, the former employee who can say how the billing was actually done, sometimes the provider. You calculate exposure across the claims that fit the pattern you have established, and where extrapolation is contemplated the sample design has to be defensible before it is drawn. Then you decide the disposition, and each one goes somewhere different — an education letter, a recovery demand, placement on pre-payment review, a contract action, a referral to the state fraud bureau, to a Medicaid Fraud Control Unit, or to federal investigators. The file has to survive being read by someone who was not there and has no reason to be persuaded: a hearing officer, a prosecutor who will decline it if it is thin, opposing counsel. Meanwhile the same provider may be disputing claims, coming up for recredentialing and negotiating a contract, and none of those teams knows what you know.