Prosecutorial Administrative Actions Successful criminal prosecution Court-ordered restitution Sanctions by professional certification boards Indictments.

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Presentation transcript:

Prosecutorial Administrative Actions Successful criminal prosecution Court-ordered restitution Sanctions by professional certification boards Indictments Warrants Arrests 1

Medical Fraud 2

Questionable Claim Referrals Indicate: – 40% of the total Casualty Referral Reasons are allegations of wrongdoing by the medical provider Duplicate Billing Excessive Treatment Provider/ Facility Improperly Licensed Billing for Services Not Rendered Solicitation Inflated Billing Unbundling/ Upcoding 2010 Medical Fraud Trends 3

Overview: Top data analytic priority identified in the Integrated Business Plan Goal is to aggregate and analyze medical billing data to identify suspect providers BOG approved NICB proposal to engage Health Care Insight in developing the AMD Aggregated Medical Database 4

Enhance NICB’s ability to combat medical provider fraud - Increase access to industry data that is non-existent today - Identify medical providers perpetrating fraud across P&C industry - Prioritize investigations of suspect providers - Publish MedAWARE SM Alerts specific to findings to participating members - Increase prosecution of fraudulent medical providers Aggregated Medical Database 5

6

MedAWARE SM Alerts MedAWARE SM Alerts are posted on the Members-Only Web Site and are viewable only to participating members. 7

8

Commercial Fraud Specialized Equipment Cargo Theft Slip and Fall Rings 9

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