The U.S. Department of Justice recently issued a press release about guilty pleas for people involved in a fraud scheme to perform unnecessary back surgeries (https://bit.ly/3CCUhJW). In this scheme, doctors, patients, and others were involved. The value of just this particular scheme is more than $31,000,000.

This scheme points out why Context 4 Healthcare does what we do, and why our fraud, waste, and abuse (FWA) solutions do what they do. This particular scheme has situations that could have been revealed through the use of Context’s FWA solutions. Specifically:

• The doctor was performing surgeries that are typically outside of the capabilities of a provider with the specialty that they’re registered for. The Context FWA solution allows you to monitor providers performing services outside of their specialty in two ways.
  • First, the Context prepayment FWA solution identifies claims where the service provider on the claim is billing a service that is outside the norm for the provider’s specialty. You can prevent payment on the claim until you’ve checked medical records and are satisfied with the evaluation.
  • Second, the Context FWA analytics solution allow you report and extract on all claims in your book of business that a particular provider or a particular provider specialty is performing. You can then delve deeper into the aberrant situations.

     

• The doctor was performing an unusually high volume of surgeries. The Context FWA analytics solution can be used to identify the abnormally high instance of procedures for a particular provider, showing the work to be outside the norm for those procedures.

   

• The patients were in on the scheme. This is one of the reasons why the Context FWA solutions contain separate watch lists for both providers and members. Once an investigation begins, it’s important to put the parties on a watch list to prevent additional claims from processing unnoticed. The Context watch lists provide that capability, and also the capability to report on activities for those on the watch list.

Helping you keep an eye on your plan is what Context is all about. To learn more about our FWA solutions, visit us at www.context4.com.