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Catching potential drug testing fraud: A case study of successful investigative techniques

On-demand webinar

Register for the on-demand webinar

As the opioid epidemic continues to ravage the nation, it leaves opportunity for bad actors to exploit the crisis and maximize their reimbursement. Opioid drug testing is an especially ripe area for exploitation and while these schemes are not new, many of them can go undetected for years due to the siloed nature of claim data across health plans.

Join Cotiviti and MetroPlus Health Plan for our on-demand webinar, Catching potential drug testing fraud: A case study of successful investigative techniques. We will discuss our collaborative case study of a New York laboratory provider identified through data analysis and its association with a previously indicted pain management provider. Through a joint effort, Cotiviti and MetroPlus Health Plan’s information sharing, link and peer comparison analyses, and a medical review of records, we were able to identify an overpayment of more than $1,000,000.

In this webinar, participants will learn to:

  • Leverage information sharing and conduct link analysis to examine relationships and connections with known bad actors
  • Utilize peer comparisons to identify outlier providers
  • Perform a thorough medical review to generate the audit findings report

Presenters:

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Shawn Mullen
Director, SIU, MetroPlus Health Plan

Shawn Mullen, AHFI, CFE is director of the Special Investigations Unit at MetroPlus Health Plan, a subsidiary of NYC Health+Hospitals, the largest municipal health system in the United States. He served 21 years as a Special Agent and Supervisory Special Agent at the FBI, where he led the FBI’s New York Health Care Fraud Task Force and served as the program coordinator for the NY Office’s Health Care Fraud Program. In 2019, Shawn received the Management Award from the DOJ’s Criminal Division Health Care Fraud Unit. Shawn is also a Distinguished Military Graduate of the Army’s Reserve Officer’s Training Corps and served as a commissioned officer in the Army Reserve, advancing to the rank of major. Shawn is a Certified Fraud Examiner (CFE) and Accredited Healthcare Fraud Investigator (AHFI).

 

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Carlyn Hoffman
Sr. Investigator, Cotiviti

Carlyn Hoffman, AHFI is a senior investigator with Cotiviti’s Program Integrity Services Team. In this capacity, she performs data analysis to identify potential fraud, waste, and abuse; prepares statistically valid random samples; and creates audit findings reports, as well as law enforcement referrals when appropriate. Carlyn also has experience surveying both members and referring providers, as well as conducting both post-payment and pre-payment investigations.