Retro Fraud: Recent Episodes
Eric Rubenstein
Former HHS-OIG Senior Special Agent Eric Rubenstein discusses historical fraud cases that either he or others investigated and how the "circus does not change, only the clowns do." In these podcasts, Eric and his guest discuss how the facts of the case have significance to today’s fraud schemes.
Eric, Wade and Matt discuss the uptick in cases involving the prosecution of providers who rely upon unlicensed or unqualified individuals to render items, services and procedures to unsuspecting patients. This, coupled with the use of excluded providers is a huge compliance concern and we provide some investigative tips for success.
Eric, Wade and Matt continue the discussion from last week's podcast on provider abrasion, with a focus on investigative planning and when to use probe sampling opposed to statistical sampling.
Eric, Wade and matt discuss provider abrasion when making requests during an investigation through the overpayment discussion. Investigators need to be confident, feel they control the conversation and not allow providers to seek "curbside justice" in the meeting.
Eric, Wade and Matt discuss the appeals process after denials are received by a provider. We take a deep dive into the ways an SIU can strengthen its position in the review, identify ways to negate some appeal issues, and provide a stronger ROI to the team.
Eric, Wade and Matt discuss errors vs. intent and the challenge of ensuring that your practice has the right safeguards in place to ensure proper coding, billing and documentation. SIU investigators are always looking for patterns, which differentiate an error from moving to an FWA issue.
Eric, Wade and Matt take a look at some of the areas of FWA from 2024 and some predictions for 2025.
Eric, Wade and Matt discuss the very interesting case of Anthony Todt, a physical therapist who was committing healthcare fraud, and also murdered his wife, three children and the family dog. We unpack this case a bit and tie it all back to the SIU world. Tune in to see how that happens.
Eric, Wade and Matt chose to discuss the cold blooded assassination that took place in NYC with a different spin.
Eric, Wade and Matt talk about the importance of identifying problems and solutions together in the SIU space. Being a manager and a leader may not be the same, but when they are, it works to benefit the organization as a whole
Eric and Matt discuss some recent work we at Advize have been doing to help stop FWA claims from being paid even before a prepay is implemented. Physical surveillance can be a low cost and very effective method of ensuring patients are actually going to the provider, among other benefits. We have seen some great results from adding this to our various #SIU offerings.
Eric, Wade and Matt discuss the importance of having consistent and complete data for accurate and consistency in investigations. Having a consistent template for your data, understanding the fields, having a data dictionary and a full billing history (including final, adjusted and denied claims) can go a long way in a fulsome investigation.
For the 100th episode special of the OIG Roundtable podcast, Jeanmarie Loria, along with several surprise guests, invades the show for an exciting and unexpected twist! The episode dives into lively conversations about healthcare compliance, fraud prevention, and regulatory oversight, featuring stories and insights from some of the top voices in the field. This milestone episode celebrates the journey so far, adding humor, surprise appearances, and a deep dive into industry challenges, making it a must-listen for long-time fans and new listeners alike!
Tune in to catch these surprises and much more as the OIG Roundtable hits its century mark.
Eric, Wade and Matt discuss the recent settlement agreement with Teva for $250 million, on top of two other settlements since 2022. Do prosecutions, settlements and penalties have an aeefect on FWA behavior? We think not.
Eric and Wade discuss a May 2024 OIG-OEI study on DME for the period 2018-2020. Over $1 billion was paid for DME during this period, and one doctor, a radiologist in California, ordered more than 20,000 DME products for patients in 44 states. It is a head scratcher for sure.
Eric, Wade and Matt discuss the current climate in staffing at SIUs and the challenges in obtaining that "perfect" position, but after a career at the OIG and in moving from one payor to another.
Eric, Wade and Matt discuss the challenges of recovering records for ancillary services. In this episode, we discuss the CMS requirement that ancillary providers obtain medical records for diagnostic and other tests to support medical necessity for that test. This can be a challenge in the SIU space, and data can help overcome the lack of provided documents from a pre or post pay review.
Eric, Wade and Matt discuss the recent settlement with Walgreens and the collateral implications of settlements in the Qui Tam space.
Eric and Wade discuss a recent Wall Street Journal article that discussed the fact that Medicare Advantage payors are having contracted healthcare providers affirmatively visit, examine and diagnose members with conditions that were potentially unknown to the members' primary care provider. Is this manipulation of risk scores or SDOH related?
Compliance is a requirement under the ACA for Medicare and Medicaid providers. Did you know you can be financially penalized if you do not have "an effective compliance program?" It is a two way street because #SIU teams also need to live in a compliant environment. We explore both sides of the street on this, and hope no one crosses the street.
Eric, Wade and Matt discuss the importance of being realistic from a vendor perspective. Often vendors promise the moon and the stars, but usually underdeliver. We discuss, in depth, the importance of expectations and level-setting for realistic results.
Eric, Wade, Matt and Jaysen discuss the unfortunate death of Friends star Matthew Perry and the implications of off-label prescriptions, the use of the Prescription Drug Monitoring Program database and how challenging cases like this are in the context of healthcare fraud, drug diversion and professional licensure.
Eric, Wade and Matt spend some time discussing the potential negative effects of an investment in SIU technology. There is a perception that increasing technology investments will lead to a greater ROI. That may not always be case, as an SIU with a backlog of reactive cases may not be able to address the proactive cases. Prioritization of cases is a key to managing the increase in leads.
Eric, Wade and Matt discuss the successes of Arkansas BC/BS under the leadership of Debbie Gunter. While we have never met her, her team's successes were recently noted in an article. We discuss and breakdown some of the ROI they are seeing and how this plan can be a model for similar plans around the country.
Eric, Matt and Wade speak about how to seek measurement of ROI when its not directly tied to financial recoveries and/or program savings. SIU teams need training, and measuring the ROI of training can be challenging. Training has to be relevant and meeting training needs is an important part of an SIU from a culture, morale and motivation perspective.
Eric and Matt discuss the difficult topic of deconfliction of complaints and investigations in an environment that does not necessarily lend itself to collaboration. The discussion focuses on duplicative efforts, the role of a law enforcement liaison, and the importance of being able to trust your FWA partners.
Eric, Matt and Wade discuss the importance of keeping an #SIU policies and procedures manual up to date and how variances in polices can reduce ROI, lead to issues in providing testimony in hearings and legal proceedings and the fact that priorities, while changing, should always be communicated clearly to the investigative team.
Eric and Wade discuss some of the common beliefs and misconceptions about operating a healthcare practice with proper guardrails and compliance measures in place. It is not about being able to afford them, it is about not able to afford not to!!
Eric, Wade and Matt discuss the recent national healthcare fraud operation, and how these events affect an SIU from a payment integrity perspective. We add in some commentary on the OIG Workplan and the implications of the Workplan as it relates to SIU operations.
Eric and Wade welcome special guest, Advize's new NY SIU Director, April Cameron, to the podcast. Fear not, April is also a retired OIG Agent out of NY, so we are keeping true to the name of the podcast. We discuss some of the skills people looking to get into the #SIU space should look to have to make them attractive candidates for a role they are interested in; certifications, internships and the like are great to stand out.
Eric, Wade and Matt discuss the prohibitive value of a press release. These documents can provide valuable insight into fraud schemes and trends, when used the right way. Social media tends to push a narrative based on the very limited information that is often provided in a press release, and taking a step back may be more beneficial in making an assessment.
Eric, Wade and Matt discuss the broad availability of information on the internet and how you are only limited by your imagination. Budgets can come and go, but the internet is free, and so is your ability to garner valuable investigative information.
Eric, Wade and Matt discuss how SIU and payment integrity programs need to always be at the front of the curve in FWA. Ensuring providers that have ill intent are prevented from gaining access to the payor, identifying the proper methods of tracking recoveries and savings, and a host of other issues are discussed in making payment integrity a living entity in an organization.
Eric, Wade and Matt spend some time discussing the challenges on investigations that involve laboratory services. Standing order issues, maintaining medical documentation from the ordering provider and some analytic challenges are all part of the investigative continuum.
Eric, Wade and Matt discuss the importance of having the proper tools in your SIU. Bells and whistles may be great, but may be too much for a plan. Generating proactive leads through data is important, but be careful what you wish for-too much can be too much!!!
Eric, Wade and Matt discuss the important role interns can have in an #SIU or similar organization. The value of educating and training a potential hire can't be stressed enough. Knowing your best candidates from a months' long "interview" can mean great future success for that person as well as the unit.
Eric, Matt, Jaysen and Wade revisit the long-standing topic of #SIU referrals. This week's episode includes a discussion of a 2008 white paper produced by CMS, specifically on Medicaid SIU interaction with MFCUs. We have been espousing many of the ideas promulgated in this document, and we take a look at some of the nuances when dealing with different stakeholders.
Eric, Matt, Wade and Jaysen discuss the importance of consistency in documenting interviews, sampling and methodologies, and having a living and working policy manual that provides that consistency for operational purposes.
Eric, Wade, Jaysen and Matt discuss on-sites in the post-COVID world. Remote employees, distance and a variety of logistics, not to be remiss to include the ROI and investigative considerations are all factors to consider when going on-site?
Eric, Matt, Wade and Jaysen discuss the ongoing issues with COVID related investigations. They focus on the changing policies, ROI for investigations, nuanced issues in data and the fraud triangle, as we see it.
Eric, Wade, Jaysen and Matt discuss the implications of deciding to conduct a statistical sample, probe or targeted sample. It is not just about the sample, but the size of the sample can create a variety of logistical, financial and operational challenges. Tune in to see what our thoughts are.
Eric, matt, Jaysen and Wade discuss propping up investigators through case reviews, identifying efficiencies from case reviews and consistency in the investigative process.
Eric. Matt, Wade and Jaysen tackle the general topic of why FWA is so pervasive and give some insights into the on-going differences in FWA based on the location. Differences in policies, investigative priorities and the like can create divergent abilities to stop FWA from happening until the money has gone out the door.
Eric, Wade, Matt and Jaysen discuss the recent data hack that has affected payments for over a week to the provider community. Outside of the costs associated with fixing this opening, there are collateral consequences for payment integrity.
Eric, Wade and Matt discuss the subtle nuances of medical necessity cases from a documentation and clinical perspective. There are investigative and ROI related issues for #siu managers, leaders and investigators. This is a not miss.
Eric and Wade discuss the US Sentencing Guidelines and how having some basic knowledge on how they work, the facts needed and the calculations that result in a potential prison sentence can be another tool in an investigator's toolbox.
Eric, Wade, Jaysen and Matt discuss internal and external sources of information and how to develop investigative techniques for using public, proprietary and organizational information that may be at an investigator's fingertips.
Eric, Wade, Matt, and Jaysen discuss a new initiative in several states where pharmacists will not only administer Strep, COVID, and FLU tests but also prescribe the associated medications for treatment. Are SIU units ready for this from an FWA perspective?
Eric, Wade, and Matt discuss how investigators often feel apprehensive about communication, both internally and externally. Investigators must have confidence in their interviewing skills, information sharing, and even testifying in hearings and trials. This week, we delve into strategies to cultivate this much-needed confidence.
Eric and Matt have Carla Shekhtman as a guest. Carla owns Echo Billing Solutions (echbillingsolutions.com) and specializes in billing for behavioral health. Carla provides insight into the important role her company plays in compliance and their internal operational measures.
Eric, Wade, Matt, and Jaysen are discussing referrals, both internal and external to stakeholders. What constitutes a good referral? Can you create a compelling argument to ensure acceptance? Why does obtaining a referral acceptance often induce such stress?
Eric, Wade, Jaysen and Matt spend some time discussing how preparation for any investigation is the beginning, middle and end of any healthcare fraud investigation. Poor preparation, and shortcutting an understanding your data, policies and setting a roadmap, are definitive ways that you will go down the wrong path.
Eric, Wade, Jaysen and Matt discuss a part of Marshall Allen's book, "Never Pay the first Bill" and his theory that the SIU (in our words) is just a cog in a wheel of a bigger business. Further, do SIUs (Special Investigation Unit's) care about identifying fraud for criminal cases? We dive very deeply into the important role SIUs have and how they can work effectively in the payor world.
This week, Eric, Matt, Wade and Jaysen discuss complaint triaging. This is the beginning of the case management lifecycle. While no cases should be placed in a "Cookie cutter" scenario, proper up front triaging is going to save a lot in seeking ROI as well as opportunity costs. Understanding data can help with this process.
Eric, Wade and matt continue their ongoing discussions on the importance of consistency. This week, they discuss interviewing and how important it is to level set with your interviewing partner to achieve the goal of the interview. Focusing on the success of a recent three-day training with an SIU client, the discussion also included the importance of preparation for the interview.
Eric, Matt, Jaysen and Wade discuss the fact that being a consistent SIU can make or break the team. having consistent processes, including documentation, referral criteria and a host of metrics, can work to make an SIU efficient. Another great discussion from real Subject Matter Experts.
Eric, Matt, and Jaysen had the pleasure of having Sean Weiss back on the podcast. They had a very enlightening discussion on the coordination of efforts in payment integrity. Sean related a recent scenario where a client of his was the subject of a TPE and passed with flying colors, yet still became the subject of a UPIC review. Tune in for the story.
This week, Eric, Wade and Matt discuss the delicate topic of SIU information sharing. While sharing information on schemes is important, plans tend to be much more closed in sharing specifics on provider cases. While there are a few organizations that seek to bridge that gap, at Advize we have found a novel way to approach the issue.
Eric, Jaysen and Matt welcome Noel Neil to the Roundtable. Noel is s subject matter expert in the DME space, and has forgotten more in the DME regulatory space than most know. A great discussion on new CMS policies, some current trends and the future of DME in the telemedicine space were covered.
Eric, Wade and Jaysen discuss the use of Targeted Probe and Education (TPE) as a behavior modification tool used by CMS and the MACs. They tackled the implications of failing TPE and the strain on resources and how TPE failures can lead to determining provider intent from an FWA perspective.
Eric, Matt and Jaysen welcomed Dr. Gary Cicio, DPM to the Roundtable. Gary has spent over 30 years in the podiatry FWA field, and was a practicing podiatrist for over 40 years. Gary is a Subject Matter Expert and has extensive experience in the commercial and Medicare space, including having been an expert witness in 13 trials. His insights were amazing.
In this episode, the crew tackles the challenges of managing an SIU with a diverse knowledge base of investigators and managing the varying priorities of an SIU that operates in multiple spaces.
Eric, Matt, Wade and Jaysen welcome Joe Croce, Director, FWA on the Advize SIU team who discussed the challenges of working with a team of investigators that come from very diverse backgrounds, including those who may have extensive law enforcement experience but not healthcare experience.
Eric, Matt, Wade and Jaysen discuss the importance of having a schedule of mandatory and enrichment training for SIU teams. Having investigators be on a "level playing field" lends credibility to the SIU team and works to increase efficiencies on the team.
Eric, Wade, Jaysen and Matt continue their discussions about the importance of ensuring SIU efficiency and operational tempos are met through. As Kenny Rogers said, "knowing when to hold ‘em, and knowing when to fold ‘em," when it comes to working leads and cases; it’s a fine line.
Eric, Wade, Jaysen and Matt continue their discussions on observations in the commercial/MCO SIU space. This podcast will discuss the need to balance the goals and objectives of the SIU with resource allocation, personnel and staff turn over.
Eric, Wade and Jaysen are joined by Advize's SME Derek Bottari, retired DEA Agent and supervisor of a tactical drug diversion team. They discuss the intersection of drug diversion and healthcare fraud, the management of resources and the implications of becoming registered to prescribe and dispense controlled substances.
Eric. Matt and Wade welcome special guest Dale Carr, Program Director, Missouri Medicaid to the Roundtable. Dale provides some great insight into how his state Medicaid program interacts with its Managed Care Organizations, the importance of coordination among different departments, the value of strong analytics and some of his "wish list" items for the future.
Matt, Eric, Wade and Jaysen discuss the global importance of training and how all training is beneficial. Return on Investment can take several directions, and not all of it is tangible dollars, but still important in operations.
Eric, Matt and Jaysen are presenting on investigative and prosecutorial trends in the FWA world. They took a time out to get together to discuss the importance of understanding the trends to make proper legal assessments.
Eric, Matt and Jaysen discuss the regional implications of FWA cases, the opportunities for fraud to be committed in one area of the country, and not hit the FWA radar of that area, and some of the important steps an SIU can take to ensure fraud schemes are being identified before it is too much of a "pay and chase."
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Eric, Wade, Matt and Jaysen are joined by special guest Earl Bock, Law Enforcement Liaison from Highmark, to discuss this little used role in an SIU. The OIG guys discuss with Earl his role, the ever increasing need for such a position, and the ways ta the role can actually facilitate an ROI to the SIU.
With Jaysen and Wade otherwise engaged in projects, Eric and Matt discussed their favorite cases as working OIG agents. Matt discussed his very first case as an agent; a psychotherapist case that took Over 20 years to be resolved (yes, you read that correctly). Eric discussed a particular podiatry fraud case that resulted in criminal and civil penalties.
Eric, Matt and Jaysen are joined by Jim Cox, retired OIG OAS Audit Manager and NYS OMIG Inspector General to discuss the new rules that will surely have an effect on Medicaid fraud in NYS.
Eric, Matt, Jaysen and Wade have a robust discussion about how the CMS Major Case Coordination (MCC) and the Immediate Advisement programs can benefit an SIU. Working to create a similar environment can pay great dividends. Tune in to see how that can be achieved and how Advize is a Best in Class in this area.
Eric, Matt and Wade have special guest Sean Weiss, also known as "The Compliance Guy." Sean has nearly 30 years of experience advising and consulting in healthcare compliance. He and the OIG team had a great discussion about the "trials and tribulations" of trials and his experiences in dealing with the government and government agents.
In this episode of the OIG Roundtable Matt, Wade and Eric discuss their thoughts and predictions on Healthcare FWA in 2023.
What is important to know, what mattes and what does not matter with Eric, Wade, Jaysen and Matt.
Capping off 2022 with another Advize #podcast episode of the OIG Roundtable with special guest Jean Stone! A historical discussion of the OIG and CMS relationship, and the Senior Medicare Patrol.
This discussion will address some of the “trials and tribulations” from having to testify, and some tips based on our retired OIG agents’ prior vast experiences.
A discussion about the NHCAA Annual Training Conference (ATC) with special guest Jeanmarie Loria.
Matt, Wade, Eric, Jaysen discuss the OIG Workplan and its implications on OIG investigations, UPIC workload and case referrals.
Healthcare fraud investigations can take years to complete and adjudicate through the courts. In this episode of the OIG Files, Eric Rubenstein, Wade McFaul and Jaysen Eisengrein discuss some of the factors that result in these delays.
Eric Rubenstein, Matt Kochanski and Jaysen Eisengrein discuss the recent OIG report on the effectiveness of the UPICS. We focused on the Medicaid criticisms and how the UPICs may, at times, be handcuffed to fully conduct Medicaid investigations due to budgets, data access and state requirements.
In this episode of Retro Fraud, Eric has an engaging discussion with Karen Weintraub. Those of you in the FWA space will know Karen as the face of Healthcare Fraud Shield. Eric and Karen have been professional and personal friends for 20 years and had a great discussion about how the human element is an absolute necessity to compliment artificial intelligence and data analytics in ferreting out false positives and false negatives in claims data.
In this episode of Retro Fraud, Eric spends some time with former Deputy Chief of the Health Care and Government Fraud Unit and long-time Assistant United States Attorney Joe Mack (Joseph G. Mack).
Joe is now in the private sector, working in regulatory and compliance for healthcare, but spent a number of years as a criminal prosecutor in the US Attorney’s Office in New Jersey, on healthcare fraud matters.
Eric and Joe worked together for many years, punctuated by the Orange Community MRI case. That case resulted in about 20 prosecutions, including 17 criminal prosecutions, and three trials in 14 months. Eric and Joe discuss this overall case, the facts and prosecutorial decisions that are made and how kickbacks continue to be a problem in the healthcare world.
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In this week’s episode of Retro Fraud, Eric speaks with Attorney Lisa Taylor. Lisa is an extremely experienced healthcare regulatory, transactional and compliance lawyer. Eric and Lisa worked together on the federal monitorship of the University of Medicine and Dentistry of New Jersey (UMDNJ).
UMDNJ was the first state operated organization to be subject to a deferred prosecution agreement (DPA). That DPA included the installation of a federal monitor to oversee many of the compliance issues that were uncovered during the investigation that led to the DPA. Lisa was the main point of contact for the monitor, and Eric was the OIG case agent on all of the cases that evolved from that monitorship. Eric and Lisa have a great discussion about those cases and the importance of good corporate citizenship.
In this episode of Retro Fraud, Eric brings Matt Lawhon back for another great discussion. Since Matt has a unique background as both a healthcare fraud investigator, and now as a healthcare lawyer, Eric brought Matt back for some continued discussions on fraud, waste and abuse (FWA).
Matt and Eric discuss ambulance fraud, and the broader policy related issues of emergency and non-emergency transports, particularly in the skilled nursing home setting. Please enjoy this informative look back-and forward, at the ongoing fraud schemes.
In episode 3 of the Retro Fraud Podcast, Eric engages in a really interesting case discussion with Matt Lawhon. Matt, who is currently a healthcare attorney in the Dallas area (M B Lawhon Law Firm, PLLC), spent a number of years both as an investigator for a Medicare contractor and as a sworn law enforcement officer for the State of Texas Medicaid Fraud Control Unit.
Matt discusses a really interesting case involving a hearing fraud scheme; only covered by Medicaid, but involved a substantialamount of money, identity theft and healthcare fraud.
The investigative results will shock you.
As we hit the ground running on our second episode of Retro Fraud, Eric interviews Wade McFaul, a retired HHS-OIG Supervisory Special Agent, who worked out of the Los Angeles Field Office.
Wade now works with Advize as the Director of Special Projects and Investigations. Wade is a wealth of knowledge and in this second episode, Wade and Eric discuss identity theft, check fraud, money laundering and how that all worked to create a huge healthcare fraud organized crime group.
Join former HHS-OIG Special Agent and Advize Director of Litigation, FWA Support, Eric Rubenstein, as he engages with fellow retired HHS-OIG Senior Special Agent Peggy Glynn.
Peggy spent over 28 years in the Buffalo, NY Field Office. Eric and Peggy tackle a discussion of a large, national case involving in-patient and out-patient claims that were fraudulently submitted to Medicare and other payors, relative to a spinal surgical procedure. This inaugural episode of Retro Fraud is one not to miss.