$112 Million Private Health Insurance Scam Revealed

Government run healthcare systems, like Medicare and Medicaid, are not the only target of insurance scammers. Two Miami area residents were sentenced to long prison terms for their roles in scheming $112 million out of private health insurers.

Daniel and Jonathan Markovich received 8 years and 16-year sentences in federal prison, respectively, for bilking private insurance companies using a “sober home” and addiction treatment services scam.

The Markovich brothers operated two substance abuse treatment centers in South Florida where they enticed patients with illegal drugs, airline tickets and cash in order to fill their facilities with insured patients.

For the Markovich brothers, insured patients were a gold mine. And by creating their own patients by supplying illegal drugs, they assured a steady pipeline of business.

The brothers would “drug” patients with a “comfort drink” to keep them coming back, keep them on their books, and allow for continual billing of millions of dollars in fraudulent services to private insurers, including Aetna, Blue Cross/Blue Shield and Magellan Health.

These services included drug detox, therapy, and urinalysis tests. Many, if not all, were medically unnecessary.

Experts in “sober home” frauds say South Florida is the epicenter of both public and private health insurance scams, with billions of dollars being billed annually.

Unfortunately, many private insurers (public as well) do not have the technology to detect these frauds, nor do they have the technology to detect other provider and billing frauds… until it’s far too late.

While cases like these make big headlines, there are perhaps hundreds of other similarly sized frauds occurring right now, running completely undetected.

Provider and billing frauds are often difficult to detect among insurance fraud teams. The sheer magnitude of payments requests can overwhelm even the largest of insurers, as it had with Aetna, Blue Cross/Blue Shield and Magellan Health in the Markovich case.

But new technologies once primarily used in the banking industry could help solve this massive, and growing problem. Real-time data analytics, powered by artificial intelligence are quickly changing the fraud landscape.

The technology, which has proven to give banks and financial institutions a massive advantage over cybercriminals and bank fraudsters, now has the capability to be utilized in the healthcare insurance industry…

And what this technology does is remarkable.

The tech, developed by ToolCASE LLC., could gather millions of healthcare provider datapoints, across thousands of sources to analyze for even the smallest of anomalies. For example, it could help detect if a provider’s billing practices are legitimate, or not. Best of all, it analyzes these data live, and could alert internal fraud and billing teams to potential discrepancies before any large payouts are made.

ToolCASE Ai has the potential to save individual insurers millions, and the global healthcare industry billions.

Discover the ToolCASE solution to healthcare fraud, HERE

Or read more about the Markovich case, HERE

Source: https://www.miamiherald.com/news/local/article259718975.html