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Pondera FraudCast

Welcome to the Pondera FraudCast, a weekly blog where we post information on fraud trends, lessons learned from client engagements, and observations from our investigators in the field. We hope you’ll check back often to stay current with our efforts to combat fraud, waste, and abuse in large government programs.

$1.5 Million to Clip Toenails?

$1.5 Million to Clip Toenails?

While I don’t think healthcare fraud is a particularly humorous subject, a recent case in Florida does lead to a few chuckles.

Earlier this year, a Northern Florida doctor pled guilty to falsely billing over $1.5 million to Medicare and TRICARE. The billings were submitted for a complex procedure that required the removal of skin and muscle. In reality, most of the procedures actually performed were for routine foot care, including toenail clippings.

So how did this fraudster get caught? It seems the authorities used basic peer comparison analytics to flag suspicious activities. In this doctor’s practice, half of his patients apparently needed the expensive foot procedure, placing him in the top 1% of all providers in the country for this service. This despite the fact that Ocala is only the 45th most populated city in, not even the nation, but the state of Florida with fewer than 60,000 citizens!

The doctor tried to cover his tracks by falsifying patient medical files to make it appear that he had actually performed the procedures, versus simply cutting toenails and performing other routine procedures. He now faces a maximum penalty of 10 years in prison and restitution of $1.5 million.

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Pondera leverages advanced prediction algorithms and the power of cloud computing to combat fraud, waste, and abuse in government programs.



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