Provider Evaluation
Founded on the principles of professionalism, integrity, and service which are paramount to the success of any investigation.
Worldwide Resources, Inc
Provider Evaluation & Fake Treatment
Fake medical bills are often issued by individuals who are genuine medical practitioners. This is because all medical bills must adhere to regulations mandating the use of a national ID, which specifies the medical practitioner involved in the transaction.
The classic scenario that often comes to mind involves a rogue doctor experiencing financial strain, resorting to inflating bills to extract additional funds from insurance carriers. While the doctor's primary medical practice remains legitimate, they may also submit claims for services or procedures that were never rendered. In many cases, these practitioners justify their actions by perceiving past mistreatment by insurance carriers, viewing their actions as a means of rectifying perceived injustices.
While instances of rogue doctors engaging in fraudulent activities certainly occur, the far more detrimental threat arises from clinics established by criminal organizations with the explicit intent of defrauding insurance carriers. In this scenario, the medical practitioner assumes a minor role in the scheme, primarily serving to lend credibility by signing forms. While willing to complete paperwork and accept payments, these practitioners are not the masterminds behind the operation. Instead, they are brought in as peripheral figures, while the orchestrators of the scheme, typically a sophisticated criminal syndicate, meticulously plan and execute every aspect of the fraud.
Instead, a sophisticated crime ring meticulously selects the clinic's location, opting for areas difficult to monitor and, if surveillance is possible, ensuring multiple entrances for evasion. They strategize the types of fraud to execute, orchestrate the staging of accidents, and recruit individuals willing to participate in exchange for a share of the profits. Moreover, they plan ahead regarding which law firms to engage should insurance companies launch inquiries and even premeditate which insurance carriers to target and which to avoid. This level of meticulous planning stems from their extensive experience; having executed similar schemes multiple times, they routinely close clinics and reopen under different names as a precautionary measure.
How it happens
Insurance companies encounter various types of fraudulent bills from medical clinics.
In cases of fraudulent billing where line items for procedures that never occurred are added, the medical clinic conducts legitimate procedures during the visit but intentionally inflates the bill by including additional procedures that were never performed. These false charges are added in an attempt to extract more money from each bill without providing the corresponding services.
In instances of upcoded line items, the medical procedure indeed takes place, but the clinic opts to code for a higher-priced version of the procedure. This often occurs with CPT codes for medical examinations, where different levels are available depending on the examination's thoroughness. Despite only conducting a cursory examination, the clinic bills for a more comprehensive and costly procedure.
In this scenario, the clinic deals with legitimate patients who have received genuine medical treatment from the provider. However, the clinic engages in fraudulent billing practices by submitting bills for additional days of treatment that never actually took place. These bills are falsified in a manner that appears plausible based on the patient's condition, despite the lack of any actual treatment on those days.
In scenarios involving visits from fake patients, collusion occurs between the clinic and individuals posing as patients. The patient willingly participates in the scheme, receiving a share of the insurance money for purported treatments that never took place. Initially, the patient may attend initial visits to avoid suspicion, particularly if the clinic is under surveillance. However, they may not return for subsequent appointments, which are still billed to insurance.
In cases of fabricated patients, the clinic operates without any involvement of real individuals seeking medical care. Instead, they generate fictitious patient records and fabricate medical bills out of thin air. This deceptive practice allows the clinic to submit fraudulent claims to insurance companies without any legitimate patient interactions.
How we spot it
We have proprietary algorithms that are constantly sifting through your data. We have
calibrated these algorithms to detect patterns in medical bills. Our algorithms are analyzing
the data from the line item level, bill level, patient level, and accident level. We have
created an impressive array of algorithms which identify bills that cannot make sense without
further explanation. Our algorithms consider not only all activity on the patient, but: all
activity on the accident, all activity performed by the clinic on other accidents submitted to
you and participating insurance carriers, and all activity submitted by the particular medical
practitioner even from different clinics. With all of this information, we are able to identify
a billing pattern that may have made sense on an individual bill (and hence not noticed by your
adjusters or bill reviewers) but does not seem plausible when considered in the totality. As
soon as this becomes apparent, these claims are flagged and immediately given as leads to your
SIU department.
Why are we different?
Our focus is to provide leads to SIU, not build a system that “pre-clears” claims. We have
seen many algorithmic systems sold with the purpose of fast tracking claims. Whether you fast
track a claim is your business; but we will analyze all claims as they go through your system
and provide a lead to SIU when potential fraud is spotted. Furthermore, our algorithms are not
fooled by people who have managed to stay out of databases related to past criminal activity,
such as recent immigrant arrivals.
Why are we different?
Our focus is to provide leads to SIU, not build a system that “pre-clears” claims. We have
seen many algorithmic systems sold with the purpose of fast tracking claims. Whether you fast
track a claim is your business; but we will analyze all claims as they go through your system
and provide a lead to SIU when potential fraud is spotted. Furthermore, our algorithms are not
fooled by people who have managed to stay out of databases related to past criminal activity,
such as recent immigrant arrivals.