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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.

Analytics are more than Numbers and Stats – It’s About People by Tammy Marple, VP - Special Investigations Unit

Analytics are more than Numbers and Stats – It’s About People by Tammy Marple, VP - Special Investigations Unit

During my time as a fraud analyst, I realized that my work was so much more than just numbers and statistics. I worked in State Government for many years and a few years ago, my manager asked me to conduct a study on Opioids. I lived that assignment for 18 months.

After the Opioid study was completed, I traveled the state and shared what I had learned with our regulatory and law enforcement partners. That assignment really stuck with me. The overall impact of the Opioid epidemic on healthcare costs, society, and the family unit is devastating. It is a sad truth when we can say “everyone knows someone addicted to these types of drugs,” regardless of how they got there. An even worse reality is the impact on the family as a whole: newborn babies born addicted to drugs, children being raised by their grandparents or in foster care because the parents are either dead or in jail as a result of their addiction and drug diversion activities, and families living with the daily possibility of overdose.

One of the most eye-opening documentaries regarding this epidemic was created by Vanguard and is titled “The OxyContin Express.” Although the video is many years old, the story it tells is still very real today and it is no longer just a Florida issue. I often suggest that our interns and new employees in Pondera’s Special Investigations Unit watch the video. It explains drug diversion schemes from drug seeking patients to the cash operations of those that prescribe the drugs, as well as the overall human element. It’s been years since I conducted the study on Opioids, and yet Opioid abuse is still on the rise and growing fast with the introduction of illicitly manufactured fentanyl.

An in-depth analysis conducted in 2016 by the Centers for Disease Control and Prevention (CDC), stated that drug overdose deaths were spreading not only geographically but also across demographic groups. Listed below are some of the stats from the CDC analysis:

• Drug overdoses killed 63,632 Americans in 2016.
• Nearly two-thirds of these deaths (66%) involved a prescription or illicit opioid.
• Overdose deaths increased in all categories of drugs examined for men and women, people ages 15 and older, all races and ethnicities, and across all levels of urbanization.
• CDC’s new analysis confirms that recent increases in drug overdose deaths are driven by continued sharp increases in deaths involving synthetic opioids other than methadone, such as illicitly manufactured fentanyl (IMF).

Pondera’s technology can identify these areas of risk in a variety of programs. This is the reason behind what we do to make a difference and potentially effect change for the better. Certainly, our goal is to detect fraud, waste, and abuse in government programs, but it really does come down to people. Sure, technology is always a cool thought when it comes to smart phones, cars that drive themselves, video games, and other advancements, but technology can also be used to detect certain behaviors within large data sets and identify highly suspect activities, patterns, or hot spots of concern. Pondera leverages technology to identify suspect activity and protect vulnerable populations within a program to make a significant difference, not only from a government budget point of view but also in the lives of our fellow citizens.

Cited Sources
Van Zeller, Mariana. “The OxyContin Express.” YouTube, Current TV - Vanguard, 19 October 2009, https://www.youtube.com/watch?v=wGZEvXNqzkM

Researchers for the Centers for Disease Control and Prevention (CDC). “U.S. Drug Overdose Deaths Continue to Rise; Increase Fueled by Synthetic Opioids.” www.cdc.gov, 29 March 2018, https://www.cdc.gov/media/releases/2018/p0329-drug-overdose-deaths.html
Largest Health Care Fraud Bust in History

Largest Health Care Fraud Bust in History

Last week, the Department of Justice announced that they had made the largest “National Health Care Fraud Takedown” in history. In all, the DOJ brought charges against 412 people in 30 states responsible for $1.3 billion in false billings. Those charged included 115 doctors, nurses, and other licensed health care providers.

Many of those busted included operators of clinics that were alleged to be illegally distributing prescription opioids—a subject that we address all too often in this blog. One Houston clinic simply sold the opioids to a room packed full of addicts and drug dealers. Another clinic in Palm Beach, FL recruited addicts by offering them drugs and visits to strip clubs. There were even cases of single doctors prescribing more medications than entire hospitals.

In their press release, the DOJ points out that 59,000 Americans died last year from opioid related drug overdoses. Many of these were from prescription opioids. This is clearly a growing problem in our country and we applaud the DOJ, HHS, and law enforcement for their efforts in this takedown. This, and similar busts, should send a strong message to the bad actors in America’s health care system.

It is important to note, however, that we still have a lot of work ahead of us. As large as these takedown numbers are, one must consider that they still represent only a small percentage of the problem. The government’s own Paymentaccuracy.gov website assigns $96 billion per year in overpayments for Medicare Fee-for-Service, Medicaid, Medicare Advantage (Part C), and the Medicare Prescription Drug Benefit (Part D). So even if all of the $1.3 billion from this bust was falsely billed in one year (which it wasn’t), it would still represent only 1.35% of the total estimated problem.

I, for one, am hoping that this is simply one of many steps in the right direction.

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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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