From the January 2015 issue of HealthCare Business News magazine
Review of large invoices — identifies invoices without purchase orders by vendor, amount, etc.
Review of payroll records — identifies potential “ghost employees” who may be on the payroll system, but who do not work for the medical facility.
Review of supporting expense documentation — involves an analysis of expenses that may not have materialized (i.e., a cancelled airline ticket) or seeking reimbursement for items never purchased.
Review of hospital bills — reviews and identifies hospital bills for mistakes, overcharges and/or duplicate charges.
Review of medical records — identifies a pattern of bills for services not rendered if supporting documents in a majority of cases are essentially non-existent.
Review of referrals — identifies an improper selection of medical providers (i.e.,unjustified favoritism of a certain medical provider). A review of the money paid to a particular medical provider for referrals can often be used to support this.
Review invoices for being false — determines whether invoiced goods can be located and/ or reviews contract terms to see if prices, amounts or terms match or exceed terms.
Medicare and Medicaid programs are the most vulnerable to fraud. Estimates of fraudulent billings to health care programs are estimated between 3 and 10 percent of total health care expenditures. The health care sector can take a more proactive approach in identifying risk factors by continuously monitoring transactions in order to identify and further reduce losses as a result of fraud.
About the author: Sareena M. Sawhney, MBA, CFE, CFFA, is a director in the litigation and corporate financial advisory services group at Marks Paneth LLP. Sawhney focuses on providing services in the areas of complex fraud investigations and forensic accounting examinations as well as services related to commercial litigation and comprehensive damage analyses.
Back to HCB News
