Clinic Fraud: Costing All of Us

In recent years, clinic fraud has become a major concern, costing insurance companies and employers billions of dollars each year. That’s not exactly chump change and each and every one of us foots the bill for these unscrupulous activities through higher insurance premiums. It seems that not a day goes by without a news story or two about someone trying to make a quick buck by scamming the system.

So, how can you take action if you believe that one or more of your claimants is involved in clinic fraud? One proven method is to conduct a clinic investigation in order to document the activities taking place at a questionable facility. Even though the folks who are involved in clinic fraud think that they’re smarter than the rest of us, a well-executed clinic investigation can quickly dispel such notions.

Clinic investigations can help you get answers to the following questions:

* Is a claim valid or not?

* Does the clinic exist or is it a mail drop or store front?

* Is your claimant showing up at the appointments for which the clinic is invoicing you?

* Is your claimant being treated by a licensed physician, a licensed physician assistant, or possibly someone without a medical license?

* Are you being billed for the cost of a physician when an assistant or non-licensed employee is actually conducting the treatment?

* Is the clinic involved with “runners,” or unprincipled parties such as tow truck drivers, body shops, or attorneys who receive incentives to send patients to the clinic?

Regardless of the firm you choose to perform a clinic investigation, their game plan should include most, if not all, of the following:

* Verifying the clinic’s physical location and inspecting the facility.

* Verifying all medical licenses of healthcare workers and medical directors.

* Conducting surveillance to determine the number of individuals entering/exiting the clinic.

* Reviewing of medical files by expert adjusters.

* Interviewing the claimant, the insured, and all medical staff on premises.

* Conducting full background checks on the owners of the clinic.

* Determining if treatment is actually being conducted and whether or not the clinic has equipment for which they are billing.

* Investigating the process of the treatment and who is providing the treatment.

* Determining if there is fraud and/or potential for a criminal referral.

When choosing a firm to conduct your clinic investigation, be sure to ask for referrals and documentation of their experience in such investigations. It is critical that the firm you select has the experience and know-how to perform the investigation in a discreet manner as many of the folks who participate in clinic fraud are well trained to be on the lookout for surveillance.

Experienced investigators will scout the location in advance of the investigation and identify the best positions to prudently document every person and vehicle coming and going from the clinic without being noticed. The last thing you want is for your investigator(s) to be detected while on-site as this will likely compromise the integrity of the entire investigation.

At Ethos, we have performed numerous successful clinic investigations for our valued clients over the years. We’ve got the experience and expertise to perform highly effective clinic investigations in a discreet manner. If you suspect clinic fraud, contact Ethos today at 866-783-0525 to learn how you can fight back and protect your bottom line.

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