Please join us at the virtual NHCAA Schemes for Health Care Fraud Investigators & Analysts conference.
Abstract
From 2016 through 2019, Medicare payments for genetic tests quadrupled. As scientists continue to make advancements in genetic testing, the landscape is everchanging. Unfortunately, bad actors can exploit the increased prevalence of genetic testing to obtain improper payments. This presentation will dive into de-identified data to show participants how to analyze their own data, using Microsoft Access and Excel, to uncover red flags. Red flags include lack of referring provider visit, repeated testing, and unqualified providers, among others we will discuss.
Participants Will Learn
How to use peer comparisons to identify outliers
How to use Microsoft Access to determine if members saw the listed referring provider
Rules and regulations surrounding genetic testing and tips to conduct a successful medical review
Participants will not only take away knowledge of genetic testing schemes, but also data analysis techniques they can use to uncover these schemes in their own data. Speakers will also showcase medical record examples to teach participants how to identify red flags in medical records.
Biographies
Jessica Gay, AHFI, CPC, CFE is the Vice President and Co‐founder at Integrity Advantage, a small woman owned business that specializes in payment integrity consulting and SIU services. She has been in leadership roles for nearly 20 years, with more than a decade spent in healthcare fraud, waste, and abuse as a business partner to more than 25 health payers and several vendors. Clients rely heavily on her expertise in SIU processes, data analytics and medical coding for strategic planning, coding accuracy audits, medical record review and training. Jess started in this industry as a trainer and loves the opportunity to speak and mentor like professionals. She has spoken at numerous NHCAA, ACFE and HCCA conferences over the years. Jessica is a Certified Professional Coder (CPC), Accredited Healthcare Fraud Investigator (AHFI), and Certified Fraud Examiner (CFE).
Carlyn Hoffman, AHFI is a Senior Investigator with Integrity Advantage Solutions with seven years of experience in Healthcare FWA Investigations. Carlyn provides outsourced SIU services to health plans including data mining, lead generation, and investigations, Statistically Valid Random Samples (SVRS), and Audit Findings Reports (AFRs). Carlyn also has experience guiding health plans through casework from discovery through provider education and overpayment resolution. Carlyn previously worked as a Senior Investigator at Cotiviti, where she also trained clients and coworkers on Cotiviti’s FWA detection products suite.