Fraud Detection Operation efforts lead to investigations

The OIG Fraud Detection Operation (FDO) team identified three behavioral health service providers who submitted claims for service that were flagged by data algorithms. Upon further review, the three providers were referred to a preliminary investigation. The flagged claims included:

• Client diagnoses that appeared to not be appropriate for these services.
• Unusual patterns of utilization and billing.

The record reviews for the three providers were completed in December 2021, which resulted in a referral to full investigation for all three. This referral will allow investigators to take a broader look at each provider’s billing and documentation patterns to determine if a violation of Medicaid policies or rules has occurred.

The FDO Team reviews large volumes of data to identify providers who appear as statistical outliers among those providing similar services. After a claim is flagged by OIG algorithms, investigators research the issue and evaluate additional evidence to determine whether an outlier’s status is attributable to possible fraud, waste, abuse or some other reason. To assist in the investigation, providers are required to cooperate with the OIG by supplying records and making staff available for interviews.