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Prosecutorial Administrative Actions

Learn about court-ordered restitution, professional certification board sanctions, and latest trends in medical fraud indictments. Discover key reasons for questionable claims and the importance of the Aggregated Medical Database to identify suspect providers. Stay informed with MedAWARE Alerts to combat fraudulent medical practices effectively.

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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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