1. Aetna Special Investigations Unit Alaska Health Care Commission June 19-20, 2014

2. SIU Focus Areas – Fraud and Abuse  Detection – Proactive data analysis identifies providers of interest based on behavior within peer group.  Investigation – Thoroughly explore all of a provider’s billing/practice behavior, not just a single issue.  Recovery – Work directly with providers to understand/educate and/or pursue recovery  Reporting, Education & Compliance – Operational and financial results reporting; mandatory anti- fraud training for employees, business associates and delegates; mandated state and federal fraud reporting  Prevention – Pre-payment claim review and routing avoids fraudulent payments Detection Investigation Recovery Prevention Reporting, Education & Compliance Major Activities  To effectively detect, investigate, and prevent health care fraud & abuse and recover benefit payments obtained by deceit or misrepresentation  To comply with state and federal regulations concerning anti-fraud plans and fraud reporting  To satisfy Aetna’s fiduciary responsibilities to its customers while leading the industry in combating health care fraud. Mission and Purpose

3. Staffing  Special Investigations Director  Medical Director  Investigative Managers  Investigative Team Leaders  Investigators  Clerical/Administrative  SIU Investigative Analysts (Field)  Info. Mgmt / Fraud Intelligence Team  TOTAL STAFF 131

4. Current Schemes

5. Source of Cases  Internal, customer service, patient mgmt., etc.  Delegates, subsidiaries and business associates  NHCAA/other insurance companies  Law Enforcement/Subpoena  Telephone Hotline, service E-Mail  Fraud & Abuse Management System (FAMS)  Outside law firms

6. 2013 Metrics  Savings & Recoveries - $300 million  Cases received – 1,800  Case inventory – 25,000  Alaska experience – 5 cases; 3 provider & 2 member  2014 Alaska open cases – 1 provider & 1 member