mhealth israel conference 2014_simon peck_head of anti-fraud_axa ppp healthcare

53
International healthcare fraud A presentation for M Health Israel Dr Simon Peck Former chair Health Insurance Counter Fraud group Medical Officer Axa PPP healthcare.

Upload: levi-shapiro

Post on 14-Jul-2015

558 views

Category:

Documents


1 download

TRANSCRIPT

Page 1: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

International healthcare fraud

A presentation for M Health Israel

Dr Simon Peck

Former chair Health Insurance Counter Fraud group

Medical Officer Axa PPP healthcare.

Page 2: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_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

Page 3: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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

Page 4: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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

Page 5: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Health Fraud

• It is like any fraud except that

– It tends to be technical in nature

– Providers > customers

Page 6: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Billing fraud

Providers

upcoding

unbundling

misrepresentation

unnecessary treatments

Customers

non-dec

misrepresentation

Page 7: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

International Fraud

Much higher than domestic business

Cannot easily check

Mostly opportunistic but some organised criminal activity

Page 8: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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

Page 9: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Convincing web presence of companies

Page 10: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Convincing web-presence of hospitals

Page 11: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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

Page 12: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

How was the case discovered

• Small errors

• Data sharing through health fraud hub

Page 13: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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.

Page 14: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Social media search

Page 15: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Management solutions

• Law enforcement => limited engagement

• Disruption –

– confiscation of premiums

– Termination of policies

– Declining all claims

– Sharing of information

Page 16: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Other schemes

• Similar scheme in South America

– Fake policies

– Fake providers

– Multiple companies hit

Page 17: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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

Page 18: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Data mining

• In my view this has four components

1. Business rules

2. Outlier analysis

3. Complex analysis

4. Intelligence management

Page 19: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Business rules

• Simple effective

Eg:

Pair violations

Consistency checks etc

Detect KNOWN problems

Degrade over time

V. effective

Page 20: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Outlier analysis

• Analyses designed to find UNKNOWN problems

• Peer grouping

• Complexity

• Frequency, cost …

Page 21: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Complex analysis

Analysis designed to find hidden patterns – iefraud which looks “normal”

A topic all on its own

Complex relationships etc

Page 22: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Intelligence management

• Integration of intelligence from other sources into data

Page 23: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

www.healthfraudhub.com

Page 24: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

www.healthfraudhub.com

Page 25: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Health fraud hub

Page 26: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Intelligence management

Page 27: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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

Page 28: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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

.

Page 29: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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

Page 30: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Pathology

So what does abuse and wastage look like in the context of path tests?

Page 31: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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

Page 32: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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?

Page 33: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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…

Page 34: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare
Page 35: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare
Page 36: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare
Page 37: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Operation labscam – the US response……

Page 38: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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….

Page 39: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Hospital offers to set up partnership with doctor

Page 40: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Hospital makes loan into partnership to build a clinic

Page 41: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

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

Page 42: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

The loan is repaid out of the clinic charges

Page 43: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Leaving the doctor and the hospital proud owners of a nice new clinic with a guaranteed stream of patients

Page 44: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

“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

Page 45: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare
Page 46: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

“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.

Page 47: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

A real path receipt

Page 48: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

A forgery of the same

Page 49: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

A pathology bill

Page 50: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Arial photo of laboratory

Page 51: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Surveillance photo of laboratory

Page 52: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Questions?

Page 53: mHealth Israel conference 2014_Simon Peck_Head of Anti-Fraud_AXA PPP Healthcare

Contact me

Dr Simon Peck

[email protected]

+44 7974 832552