Investigating Health Insurance Fraud

The life of an average insurance fraud investigator isn’t anything like on TV. There aren’t late-night shootouts or wild car chases to track down bad guys.

In fact, most fraud investigators’ work begins in an office, running computer programs to detect unusual payment patterns and taking calls from informants.

Meet Gary Auer, director of the Special Investigations Unit for Nevada health insurer Anthem Blue Cross.

Auer once was a special agent with the FBI who specialized in bombings, white-collar crime and union corruption. Today, he oversees 28 investigators assigned to addressing fraudulent billings submitted by medical providers.

Auer uses his computer to identify leads. A program highlights suspect billing patterns and particularly high charges from doctors. Auer’s office also gets calls from whistleblowers.

His team evaluates each case much like a police officer would.

“I ask, ‘Is this a fraud that is just a mistake in billing, or is it criminal fraud?'” Auer said. “If it’s fraud, I have a second issue to address: Do we have an investigative agency that will care? Most police agencies, because of constraints on their personnel, are primarily concerned not with white-collar crime but with violent crime and drug crime. So when we see fraudulent submissions, we’re looking to see if there’s a police agency in the county that has the personnel dedicated to working white-collar crime and health care fraud.”

Auer also has to determine whether there are prosecutors available to handle a case.

“If we have a prosecutor in Nevada that’s interested in prosecuting health care fraud, then I’m much more likely to open a case,” he said.

Auer said Nevada generally is more active in prosecuting health fraud cases than other states because the U.S. Attorney’s Office and state attorney general’s office aggressively pursue the issue.

“What’s unique in Nevada is that there’s a quarterly meeting that’s jointly sponsored by the U.S. Attorney’s Office and the Nevada attorney general,” Auer said. “They have a very cooperative working relationship. There’s little or no competition between the agencies over who’s getting the case. There’s clearly a determination by both the state and the federal agencies that we’re going to do what’s best for the health care industry.”

Last year, Auer’s office opened fewer than 100 health care fraud cases in Nevada. Health insurance scams are much more prevalent in Florida, California, Georgia, Texas and New York.

Once the computer flags a case, Auer matches it to an investigator.

“His or her job will be to develop more facts,” he said. “It may be necessary to get additional medical records. They also have to investigate further what the medical billing rules are to determine whether, in fact, we can establish that the services were not actually rendered, to determine the extent of the losses involved. I may turn to our nurses for further data review.”

Investigators describe any issues found to the medical provider and ask him or her to explain the billing.

“What we try to do is have them call us to discuss with us the accuracy of the billings so that we can reach an appropriate and equitable resolution,” he said. “For the investigator, it’s building a case, gathering all the facts and giving the provider the opportunity to tell us we’re wrong.”

What kinds of cases do investigators see? Generally, billings for services that weren’t rendered, including consults that never occurred or equipment that never was delivered, and treatments that are improperly identified by doctors or third-party billers.

“There’s a built-in incentive for the doctors or the billers to be very liberal in their interpretation of the billing codes,” Auer said. “One biller told me, ‘My mission is to push the envelope, to break out of the box’ on the billing requirements. Of course, my response to him is that it’s my job to keep you in that box and bill according to the law.”

Another big issue — one that has drawn considerable attention from Southern Nevada law enforcement — is prescription drug abuse, particularly pain killers. Auer said investigators have increased efforts to track down doctors who prescribe large amounts of drugs such as Oxycodone.

“Maybe I’m going back to my law enforcement background, but it was one thing for the Colombian and Mexican cartels to be running heroin and cocaine into us and for us to be paying for it,” he said. “This is different because we’re killing more people with this as a prescription drug, and we’re using the American taxpayer’s money. We’re using dollars from the health care system to kill our own citizens.”

Auer said his company uses computer analytics to identify high prescribers of prescription drugs and determine whether the patients receiving them have a reason to use them. If they don’t, the company forwards the information to local law enforcement.

Auer’s team also includes clinical investigation nurses who watch for coding submissions on billing forms. In Nevada, there is an above-average use of “global billing codes,” in which an entire package of medical procedures is submitted under one code. The problem is that, in some cases, procedures listed in the bundle also are billed separately.

Auer said his job satisfaction comes from his efforts to drive down the cost of health care.

“From my perspective, it’s the most important public policy issue facing the country at this time,” Auer said. “Whether or not you agree with Obamacare and whether Obamacare existed or not, too much of this nation’s economy is going into the health care system. I think the country as a whole recognizes that we’re spending a lot more money than the rest of the world and not necessarily getting the best care. We’ve got to do better, not just for our members and all our citizens, but for the entire health of our economy.”

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