ACFE-Heartland
Chapter
Luncheon
Meeting
"Healthcare
Fraud 101"
Tuesday, July
12th, 2005
Park Inn
Regency Lodge
Our guest speaker for our
meeting was Mr. Dennis Keenan. Mr.
Keenan is an SIU manager of healthcare fraud investigations for Mutual of
Omaha. Mr. Keenan stated that the best
estimates of healthcare fraud range from 6-10% of all healthcare
expenditures. This estimate equates to
approximately $180 billion in fraudulent healthcare expenses each year. With our aging population, a growing
percentage of healthcare fraud is being perpetrated in the pharmaceutical
arena.
Mr. Keenan stated that the
primary responsibility of the SIU is to safeguard company assets utilizing
several mechanisms. These include
investigations, education, compliance, internal teamwork, and external
networking. SIU investigators utilize
data mining, information sharing, in house referrals, hotlines, and internet
mailboxes. There are several potential
fraud indicators which are often referred to SIU for investigation. These include overutilization of treatment,
questionable treatment methods, hyperitemization, altered documents, and
upcoding/fee splitting.
Mr. Keenan stated that a
typical investigation begins with a referral, research, collection of evidence,
and interviews. Cases are resolved in a
number of ways depending on the particular facts of each individual case. These resolutions can include criminal or
civil actions, administrative or managed care network resolutions, changes to
internal controls, out of court settlements, or no action at all. Providers can also be shut out of various
information sharing networks, effectively closing their businesses.
