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Prosecutorial Administrative Actions

Prosecutorial Administrative Actions. Successful criminal prosecution Court-ordered restitution Sanctions by professional certification boards Indictments Warrants Arrests. Medical Fraud. 2010 Medical Fraud Trends. Questionable Claim Referrals Indicate:

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Prosecutorial Administrative Actions

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  1. Prosecutorial Administrative Actions Successful criminal prosecution Court-ordered restitution Sanctions by professional certification boards Indictments Warrants Arrests

  2. Medical Fraud

  3. 2010 Medical Fraud Trends • Questionable Claim Referrals Indicate: • 40% of the total Casualty Referral Reasons are allegations of wrongdoing by the medical provider • Duplicate Billing • Excessive Treatment • Provider/ Facility Improperly Licensed • Billing for Services Not Rendered • Solicitation • Inflated Billing • Unbundling/ Upcoding

  4. Aggregated Medical Database Overview: • Top data analytic priority identified in the Integrated Business Plan • Goal is to aggregate and analyze medical billing data to identify suspect providers • BOG approved NICB proposal to engage Health Care Insight in developing the AMD

  5. Aggregated Medical Database • Enhance NICB’s ability to combat medical provider fraud - Increase access to industry data that is non-existent today - Identify medical providers perpetrating fraud across P&C industry- Prioritize investigations of suspect providers- Publish MedAWARESM Alerts specific to findings to participating members- Increase prosecution of fraudulent medical providers

  6. Aggregated Medical Database

  7. MedAWARESM Alerts MedAWARESM Alerts are posted on the Members-Only Web Site and are viewable only to participating members.

  8. Commercial Fraud Specialized Equipment Cargo Theft Slip and Fall Rings

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