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FRAUD, WASTE, AND ABUSE PREVENTION

Case study: How to build a strong healthcare fraud case leading to conviction

Special investigative units (SIUs) work diligently to find and prevent healthcare fraud, waste, and abuse (FWA), but getting from an initial tip to a conviction is not easy. The most successful SIUs rely on robust data analysis and reporting tools to build their case before presenting evidence to law enforcement. One major Minnesota health plan leveraged Cotiviti’s FWA Solutions to break down a chiropractor’s unusual billing patterns—such as submitting claims for more than 150 patients on a single day—ultimately leading to his conviction for billing for services he never actually performed.

“Any time you can get a law enforcement agency to accept your case and move forward with it, especially if it ends with a prosecution, that’s a really successful outcome on any case,” said the health plan’s SIU manager. He added that having advanced data analytics and lead generation software at the team’s disposal makes their efforts much faster and more efficient. “This is a complicated job—it’s not easy for most people to understand what you’re looking at or what you’re looking for. The tools we have available to us from Cotiviti are essential to our investigations.”

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WRITTEN BY

Mark Starinsky, AHFI, CFE, CHC
Mark is the product director for Cotiviti’s fraud, waste, and abuse (FWA) solutions. He has more than 20 years of healthcare FWA investigative experience, specializing in healthcare regulatory compliance, developing policies and programs to meet federal and state government regulations, and business planning for change initiatives and turnaround management. Mark has also presented on fraud schemes at numerous conferences including NHCAA’s Annual Training Conference.

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FRAUD, WASTE, AND ABUSE PREVENTION

Case study: How to build a strong healthcare fraud case leading to conviction

Mark Starinsky, AHFI, CFE, CHC

Jan 16, 2020

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