To build a better fraud trap
Minnesota companies Ingenix and Fair Isaac are each working on technology to help identify false claims that contribute to skyrocketing health-insurance costs.

BY JULIE FORSTER
Pioneer Press

Ferreting out intentional crime from a legitimate mistake or simply a difference in opinion between a doctor and insurer is not always black and white. *Robin Mathias*, a health care fraud consultant based in Santa Rosa, Calif., noted that while it is cutting edge, the technology is not as clear-cut when used to find health care fraud as it is in finding fraud in the credit card industry.

Janet Reno spoke today at the National Conference of the Gay and Lesbian Medical Association. As a GLMA Board Member, I had the opportunity to chat with her briefly after her presentation.

Ms. Reno spoke about how important it is for all people to have access to healthcare. If minorities are protected from discrimination in healthcare but do not have the financial ability to access care, then the rights are only paper and not real. She gave many examples of how lack of health coverage harms our population. And she talked about the costs that could be avoided by having universal coverage. Ms. Reno also stressed the importance of helping the elderly stay in their homes and avoid nursing home care.

First of many? Vaccine probe may extend beyond Connecticut

Byline: Mark Taylor

This is an excerpt. Click the link to view the full document.

Last week’s settlement by a Connecticut hospital could be just the first as state Medicaid fraud-control units explore allegations that hospitals, physicians and other providers may be billing Medicaid and private insurers for children’s vaccines they received free, according to government sources and healthcare fraud experts.

Healthcare billing fraud consultant Robin Mathias, former director of data analysis and budget for Indiana’s Medicaid program, said the vaccine billing scheme has likely spread beyond Connecticut’s borders.

“Regardless of what the federal agencies are saying, I suspect that other Medicaid programs will be looking into whether they’ve been billed for the VFC free immunizations,” said Mathias, who advises health plans about fraud schemes. “Whether or not it was fraud or an honest error, those providers would have been essentially paid twice for the same service, and that’s illegal.”

She said hospitals, many of which operate outpatient, immunization and community clinics, could face liability.

The US Department of Justice is investigating allegations that Medtronic, Inc. paid illegal kickbacks to physicians. Jim McCartney of Pioneer Press contacted Mathias Consulting and wrote this report published Sept 9:

“Unlike the government’s criminal sting operation, the allegation against Medtronic was apparently brought by an individual or individuals as part of a “civil qui tam complaint brought pursuant to the federal False Claims Act,” according to the company’s disclosure.

The qui tam provision allows private individuals to bring civil cases against entities that have submitted false claims to the government. The person who brings the case to the government’s attention (and their lawyers) can win a substantial portion of the final settlement or judgment, said Robin Mathias, a health care fraud consultant based in Santa Rosa, Calif.

There has been an increased number of probes into health care fraud, especially involving the Medicare system, Mathias said. The qui tam provision has been ‘a great incentive for people to turn in their bosses for committing fraud’ and has been used extensively in Medicaid and Medicare fraud cases, she said. Most states now have hotlines set up for reporting Medicaid fraud. ”

“Even so, the vast majority of fraud is not caught,” Mathias said.

Read the article at the Pioneer Press Medtronic division accused of payoffs

In a sting known as “Operation Headwaters,” FBI agents found a company allegedly advising other companies how to get reimbursed for their products, even though the products are not covered by Medicare.

Mike Fitzgerald covered the story in the Belleville News-Democrat. He contacted Mathias Consulting to find out more about Medicare fraud:

“Medicare is a tempting target to scam artists because it is an entitlement program. Most of its annual budget comes from the pockets of taxpayers, and not directly from its elderly customers, said Robin Mathias, a health care fraud investigator based in Santa Rosa, Calif.

‘You don’t have the same kind of natural built-in controls that you have for credit-card fraud,’ Mathias said, ‘because the customer, the patient, often doesn’t see the billing or have as much interest in making sure it’s accurate.’”

Read Mike’s article

Robin Mathias appeared in a live interview on CNBC’s Business Center on November 11, 2002. Following a recent FBI raid of Tenet Healthcare Systems for alleged Medicare fraud, Robin was asked her expert opinion on trends in healthcare fraud.