mhealth israel conference 2014_simon peck_head of anti-fraud_axa ppp healthcare
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International healthcare fraud
A presentation for M Health Israel
Dr Simon Peck
Former chair Health Insurance Counter Fraud group
Medical Officer Axa PPP healthcare.
Conflicts of interest
• I am an employee of Axa PPP healthcare part of the global Axa group
• I have no commercial interests outside of this
The UK health system
All UK residents are entitled to free healthcare from NHS
10% buy health insurance.
There are a number of private hospital chain in the UK
BMI
Spire
HCA
Nuffield
Ramsay
Axa PPP healthcare’s business
Provision of private medical insurance
1. Domestic in UK, Europe, Gulf, Asia, Mexico
2. Expatriate medical insurance
3. Travel and emergency medical assistance
Health Fraud
• It is like any fraud except that
– It tends to be technical in nature
– Providers > customers
Billing fraud
Providers
upcoding
unbundling
misrepresentation
unnecessary treatments
Customers
non-dec
misrepresentation
International Fraud
Much higher than domestic business
Cannot easily check
Mostly opportunistic but some organised criminal activity
Organised criminal activity
The following case is under investigation so I can only give outlined information
• Fake SME and individual policies sold by US and UK insurers from outside UK or US jurisdiction
• Multiple electronic applications
• Charges made from fake clinics outside US and UK jurisdiction
• Proceeds paid into bank accounts in UK and US
• Losses $M
Convincing web presence of companies
Convincing web-presence of hospitals
Other factors
• All transactions electronic
• Hospitals in distant locations unlikely to be known
• Language issues
• Convincing documentation
• Lack of police interest
• Not excessive but claims > premiums
• => not easy to deal with
How was the case discovered
• Small errors
• Data sharing through health fraud hub
OSINT investigation
• Open source intelligence revealed:
– Companies and hospitals have same domain registration details
– Identified IP address
– Using “reverse who-is” – further hospital domains identified some banked some previously used.
Social media search
Management solutions
• Law enforcement => limited engagement
• Disruption –
– confiscation of premiums
– Termination of policies
– Declining all claims
– Sharing of information
Other schemes
• Similar scheme in South America
– Fake policies
– Fake providers
– Multiple companies hit
Management in one slide
So for example a company with a basic capability would be expected to have a designated person, a procedure to deal with suspect claims etc
A sophisticated company would have a multi-disciplinary team (law-enforcement, medical, claims, lawyer, accountant compliance officer.)All ACFS qualified
Data mining
• In my view this has four components
1. Business rules
2. Outlier analysis
3. Complex analysis
4. Intelligence management
Business rules
• Simple effective
Eg:
Pair violations
Consistency checks etc
Detect KNOWN problems
Degrade over time
V. effective
Outlier analysis
• Analyses designed to find UNKNOWN problems
• Peer grouping
• Complexity
• Frequency, cost …
Complex analysis
Analysis designed to find hidden patterns – iefraud which looks “normal”
A topic all on its own
Complex relationships etc
Intelligence management
• Integration of intelligence from other sources into data
www.healthfraudhub.com
www.healthfraudhub.com
Health fraud hub
Intelligence management
Assessing matches
match
Names Postcode DOB Names Postcode DOB Names Postcode DOB
Simon Peck TN12PL 17/01/1968 Simon Peck TN12PL 17/01/1968 0 0 0
Ray Collins TN25FE 27/06/1970 Raymond Collins TN25FF 10/12/2964 20 100 1000
Pathology
Lets look at fraud and abuse in the context of a small area of healthcare – pathology – a microcosm of health insurance fraud and scams
.
Thoughts from Harvard University
In the hands of those who would steal one of the most valuable commodities in the business is a vial of blood…there is virtually no limit to how many tests you can do.
Prof Malcolm Sparrow
Harvard University
License to steal ISBN
Pathology
So what does abuse and wastage look like in the context of path tests?
Unbundling and overcharging
• Charging of tests at hugely inflated values – eg a FBC costs £2.50 – we have seen this billed at £200
• Charging for parts of a test separately eg:– RBC
– Hb
– WBC (& differential)
– Platelets
– MCV
– MCH
– MCHC
– PCV
Pathology Profiles – a minefield…. Path tests are grouped on an order form.Some groupings are legitimate. Some include inappropriate tests which are ordered by defaultSome are set deliberately out of synch with purchaser contracts – so 1 item = 2 bills.When you see a profile ask – do I really need to order all these tests?
A UK Case study
The X laboratory is a provider of pathology services to private and NHS (government) hospitals.
We noted that the order forms used in the two sectors were very different
The NHS order form is designed to minimise the tests ordered
The private sector form combined common tests in groups with large numbers of tests which would not ordinarily be ordered as a routine
The numbers of tests ordered were compared between the two groups. The results were very striking…
Operation labscam – the US response……
Kickbacks
Here is an extract from a statement made by an eminent London physician
when we questioned him about the very large number of blood tests he was
ordering….
Hospital offers to set up partnership with doctor
Hospital makes loan into partnership to build a clinic
The doctor then refers patients into the clinic. He may not tell them about the arrangement and may well not be concerned how expensive the clinic is. Patients believe he has only their interests at heart
The loan is repaid out of the clinic charges
Leaving the doctor and the hospital proud owners of a nice new clinic with a guaranteed stream of patients
“Non standard tests”
• We have seen the growth of pathology labs offering non-standard and non-evidence based testing:
• Gut fermentation tests
• Hair allergy testing
• Environmental toxins
• We have seen single patients run up £10,000 of non-standard tests
“Sink” testing
Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu
FBC 2 3 1 2 2 0 0 2 3 3 3
U&C 2 1 4 2 3 0 1 1 2 1 2
clotting 1 1 1 1 1 1 1 1 1
Repeated and unnecessary testing of blood samples for financial gain. In any one case it
is hard to challenge. Who knows if the tests really took place or the blood was simply
poured down the sink.
Some analysers store blood for 24-48 hours and extra tests can be ordered from the
original sample at the touch of a button…..
Below is a real example of path billing – note the repeated testing – not however at
weekends when overtime rates are being paid in the lab.
A real path receipt
A forgery of the same
A pathology bill
Arial photo of laboratory
Surveillance photo of laboratory
Questions?
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