Insurance fraud, waste, and abuse are major factors in the rising cost of health care in America today ? costing consumers as much as $1 out of every $7 spent on health care. The Corporate and Financial Investigations Department (CFID) at AmeriHealth is doing its part to address this problem by identifying, investigating, and reporting suspicious cases of abusive practices to law enforcement authorities. In addition, recovery of overpaid claim dollars is pursued, regardless of the reasons.

2011 in review

Pennsylvania and Delaware. Last year the CFID received 986 allegations of fraud, waste, abuse, or aberrant billing practices, with 116 of these allegations coming from providers or members. Because of these allegations, 106 fraud and abuse investigations were initiated. Additionally, audits of 116,106 hospital claims and 237 professional and ancillary service provider audits were conducted, as well as 2,974 pharmacy drug utilization desk audits and 496 pharmacy retail site audits. Evidence gathered in 2011 resulted in 42 referrals to law enforcement or regulatory authorities. Of this number, five pertained to members, 13 to doctors, and eight related to prescription fraud.

New Jersey. Last year the CFID received 216 allegations of fraud, waste, abuse, or aberrant billing practices, with 20 of these allegations coming from providers or members. Because of these allegations, one fraud and abuse investigation was initiated. Additionally, audits of 4,377 hospital claims and 13 professional and ancillary service provider audits were conducted, as well as pharmacy drug utilization desk audits and pharmacy retail site audits. Evidence gathered in 2011 resulted in five referrals to law enforcement or regulatory authorities. Of this number, three pertained to doctors or health care professionals.

Trends and results

Through the use of sophisticated data mining software tools, the CFID analyzes all claims submitted by medical providers, facilities, and pharmacies and compares them against member enrollment data and overall provider information. Trends, patterns, and aberrant billing practices are selected for in-depth audits or investigations. The most often used fraud schemes were:

• billing for services not rendered;
• "up-coding" procedure codes on claims submitted in order to receive a higher reimbursement;
• prescription fraud.

Because of the investigations and audits performed by the CFID, $1,175,282 was recovered with an additional $110,504 in overpaid claims identified but not yet recovered. Charges were brought against two individuals during the past year. In addition, one individual pled guilty to questionable billing practices and was sentenced to 36 months probation.

We need your help

Although the CFID continues its efforts to ensure that health care costs are appropriate, we still need your help. The data mining software tools and fraud hotline both provide valuable leads, but there is no substitute for your own vigilance. Allegations received from our provider community are extremely valuable, and we ask you to contact the CFID if you are suspicious of any health care activity. To do so, please call our toll-free Fraud and Compliance Hotline at 1-866-282-2707 or go to the Anti-Fraud page on our website.