Feds Allege Massive Multi-State Provider Fraud

Feds Allege Massive Multi-State Provider Fraud

A lawsuit filed in the US District Court for the Southern District of Illinois alleges General Medicine P.C. “played a numbers game designed to bill as many patient visits as possible, regardless of whether those visits were actually performed as documented or medically necessary.”

The healthcare provider, based out of Michigan, is alleged to have fraudulently billed Medicare for long-term care patients across multiple states over the course of years.

The government believes General Medicine P.C. billed for an abnormal amount of patient visits, and billed for complex appointments when visits were routine, an illegal practice known as upcoding.

The suit claims that on one day alone in 2017, a doctor working for General Medicine reported the visit of 40 patients. The coding showed each appointment should take roughly 35 minutes. Had that been the case, this particular doctor would have worked 23 hours that day.

This is a red flag that, with modern fraud solutions, could have been detected the moment the codes were uploaded.

Now, these alleged provider frauds go back as far as April of 2016 but may have begun much earlier, perhaps on a smaller scale.

Between April of 2016 and March of 2021, the company received over $40 million in reimbursements from Medicare Part B, much of which the government alleges was fraudulently obtained.

The suit names Dr. Thomas Prose, General Medicine P.C., and 17 other corporate entities.

It is believed the fraud spanned eight states: Illinois, Kansas, Ohio, Missouri, North Carolina, Michigan, Louisiana, and Iowa.

This alleged fraud, going back to at least 2016, could have potentially been detected long before Medicare payouts were made.

New artificial intelligence technology now has the capability to detect healthcare frauds live, as they’re occurring.

By analyzing millions of datapoints from patients, providers, emergency services, pharmacies and intermediaries, Ai could uncover even the smallest discrepancies in expected outcomes.

For example, Ai for fraud detection could have seen a 23-hour workday as a potentially fraudulent billing scheme as it was happening, and alerted Medicare (in this case) to the issue.

Artificial intelligence has the ability to detect fraudsters who operate even the smallest of provider scams by accumulating and interpreting data live, at an accuracy and speed unattainable by the human eye.

By stopping small scams before they become large ones, Ai could save health insurers potentially billions in unwarranted payouts derived from fraudulent activities.

Of course, Ai won’t replace human fraud teams, its only a new tool to add to their arsenal. But it’s a tool that must be utilized as the entire system is under threat.

Could this cutting-edge Ai technology, offered by ToolCASE, have prevented the alleged General Medicine P.C. fraud?

Find out more, HERE

Or, read more about the General Medicine P.C. case, HERE

Source:  https://www.stltoday.com/business/local/feds-sue-southern-illinois-nursing-home-provider-alleging-years-of-fraud/article_5110aaaf-974b-52ef-9d6c-90686795e130.html

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