- New Jersey lawyer John Mininno identified five “red flags” that signal a medical practice or healthcare company may be scamming Medicare, Wired reported.
- Using statistical analytics, Mininno looks for patterns in claims filings, identifies possible whistleblowers within the firm and encourages them to file a false claims lawsuit.
- In 2014, fraudsters bled $60 billion from Medicare, or about 10% of the program’s annual spending on 54 million beneficiaries.
Since 2007, the government has charged more than 2,300 providers with Medicare fraud, convicting 1,800 of them. But the problem shows no signs of abating. While the government can and does bring cases against alleged fraudsters, a more successful route has been qui tam lawsuits, which recouped $2.2 billion in fines last year.
Mininno formed the National Healthcare Analysis Group to hunt for shady practitioners and businesses, amassing evidence using analytics to pour through claims data and detect specific behaviors or characteristics.
His five red flags for Medicare fraud are:
- Patient billings are too regular, with no variation in patient visits and follow-up visits always billed on the first allowable day;
- Patients always require the maximum number of allowable visits;
- Frequency of billings doesn’t fit a bell curve, but clusters around thresholds for additional payment;
- Providers associate with practices or providers that have been investigated for fraud; and
- Facilities get most of their referrals from physician owners.
As with any list, there are caveats. Mininno cautions that high billings aren’t always a sign of fraud because some physicians legitimately treat patients with very expensive medications in their office.