Skip to Main Content
VISUALIZE | INSIGHTS THAT POWER INNOVATION

Is your organization vulnerable to emerging provider fraud trends?

The concept of new and emerging provider fraud trends doesn’t only apply to recent medical providers showing up on your radar. Even if you’ve historically worked suspect provider cases, successfully mitigated exposure, and set up safeguards to address the issues you uncovered, you still must monitor those providers going forward.

Some suspect medical providers you’ve successfully identified in the past may find other ways to make up for the dollars you stopped. I recommend monitoring your exposures to previously investigated providers at least once every 6-12 months.

To illustrate the importance of this practice, let’s examine a real provider example. The dollars in the case are real. For publication purposes, the provider’s name has been fictionalized. (Check out part one of this blog series to see the importance of handling low-exposure provider cases.)

Visualize Blog Chiropractor

The ‘sneak and peek’ scheme

For six years, between June 2013 and July 2019, Dr. Bone Breaker’s suspected fraud, waste, and abuse (FWA) dollars billed took an interesting course. In 2013, his billing was limited to just one threat, but it was significant—a $2,110,452 exposure. Effectively, Dr. Breaker was a major outlier for the unusually high number of visits he was billing per patient.

It appears that the SIU handled this threat well because his billings dropped dramatically. When Dr. Breaker reappeared on the radar two years later in 2015, the single, significant billing threat from 2013 was gone, but eight new smaller ones emerged. His new FWA exposure was $409,383 (a 135 percent difference from the prior level).

This time, Dr. Breaker was engaged in template treatment, billing for more hours than reasonable in a single day, billing a higher rate of chiropractic manipulation treatments than would be expected, and billing questionable mechanical traction treatments, to name a few.

I refer to the type of emerging trend Dr. Breaker employed as “Sneaking and Peeking.”  With this scheme, the suspect provider attempts to sneak in some new billing threats, then peeks (sits back, waits, and watches) to see how – if at all – the insurer reacts to the new schemes.

Imagefz79j

Regarding Dr. Breaker’s 2015 billing threats, it doesn’t appear that much SIU detection or reaction occurred. When 2019 rolled around, Dr. Breaker’s billing threat exposure had grown from $409,383 to more than $1.7 million. His threats included seven of the eight from 2015’s billings, and to round out the eight, he reinstituted the original billing threat he used in 2013.

Keeping an eye on questionable providers

Using the example of Dr. Breaker, we can see how his billing threat behaviors started and stopped then, after a period of being careful, he tested the waters again. With no appreciable abatement of his emerging (or re-emerging) billing practices, he was emboldened to continue raking in the money. Over time, he generated a 329 percent increase in his FWA billing from 2015.

By re-examining exposures to medical providers you have successfully worked in the past, you keep your awareness alive. You may find that some of those providers are still hitting you, just from different angles now. This is especially true of providers who live a lifestyle based on the FWA dollars they rake in.

Never forget: for professional fraudsters to maintain their standards of living, they must find new and further ways to replace losses experienced from past SIU interventions. Creating and maintaining a provider monitoring protocol is a critical component in detecting new and emerging provider fraud trends.


Bo Barber, CFE

Bo Barber, CFE, is director of investigative analysis for Verisk’s anti-fraud solutions group. For more information on how Verisk can help your organization detect medical provider fraud, contact Bo.Barber@verisk.com.


Visualize Subscribe

Get the best of Visualize!

We'll send Visualize Monthly, and our most popular content, right to your inbox.

Subscribe now

You will soon be redirected to the 3E website. If the page has not redirected, please visit the 3E site here. Please visit our newsroom to learn more about this agreement: Verisk Announces Sale of 3E Business to New Mountain Capital.