Investigating Claims Data Leads to Eye-Popping Findings

As a part of ĤƵ’s Payment Integrity service, we review claims to ensure there are no billing errors and that the charges make sense. When we find mistakes or suspicious charges, we investigate. Below we share some eye-popping findings from our Payment Integrity team’s investigations.

The Fountain of Youth exists and it’s located in a doctor’s office

That’s what claims data from a specific doctor would have you believe. The provider ordered countless tests and performed multiple procedures time and time again to combat “anti-aging.” Each test/procedure costs between $12,000 to $18,000.  Our algorithms flagged the claims for excessive testing and the extraordinary number of procedures performed, and our medical experts confirmed the tests and procedures were inappropriate. We are in the process of removing this provider from ĤƵ’s networks. Sadly, there is no evidence the Fountain of Youth has been located.

There’s a diagnostic test for fibromyalgia, but apparently only one medical laboratory knows about it.

Currently, there is no lab or imaging test to diagnose fibromyalgia. Doctors diagnose the condition by ruling out other causes for fibromyalgia’s symptoms, which are primarily pain and fatigue. That’s why we were surprised to find a medical laboratory advertising a fibromyalgia test. We became aware of the provider after receiving almost 500 claims with charges of approximately $10,000, all with the same diagnosis of immunodeficiency diagnoses. This caught our attention because it’s a rare disorder with only 1 case out of 50,000 worldwide.

The same 15 immune system tests were repeatedly billed on multiple claims. ĤƵ investigated and found the  provider was billing the 15 tests, but calling it a Fibromyalgia Test. Worse, none of the patients in the claims we reviewed had the diagnosis reported by the provider. If a test for fibromyalgia is ever developed, we believe it will be big news and not a secret kept by one medical laboratory.

It turns out past life regression cures some sick patients.

Investigating questionable charges led us to a provider who advertises that some illnesses may have originated in a past life, and past life regression may cure them. The provider also claimed to be able to contact the dead. We became aware of these assertions because the provider filed multiple claims with charges of $2,000 each for office visits that included an electroenchephalogram (EEG).

EEGs are used to detect seizure activity and localization of seizure activity, and trained EEG technicians typically perform them. Neurologists interpret the results. The provider’s credentials did not include any EEG technical or neurology academic or practical qualifications. These claims were repeatedly filed for the same patients, and some patients received multiple EEGs within 1 or 2 week time frames. This caught our attention, so we investigated. The provider admitted to not performing the EEGs. She billed for them because what she actually did was not reimbursable. We have removed this provider from ĤƵ’s networks.

Learn more about ĤƵ’s Payment Integrity services and let us find out what’s hiding in your claim data.