Provider fraud found in review of HMO network

Problem: Provider network contracting reviews were planned because the HMO client suspected provider fraud might exist. Management wanted to know how current contracts were being enforced, wanted to pinpoint providers whose contract renewals might be questioned, and desired to quantify the extent of provider fraud.

Action: Health Decisions reviewed contract language and developed custom computer programs to confirm the extent of network contract enforcement. A series of provider payment reviews were conducted to compare provider billing practices. Health Decision used its technical capabilities to search and analyze information from 17 federal government databases as part of its investigation.

Result: Client learned that numerous contract provisions were not being enforced and that simpler contracts with fewer exceptions should be implemented. A small number of providers with questionable billing practices were identified and eliminated from the network, eliminating more than $50,000 in fraudulent billing.