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Aetna Special Investigations Unit

Aetna Special Investigations Unit. Alaska Health Care Commission June 19-20, 2014. Mission and Purpose. To effectively detect, investigate, and prevent health care fraud & abuse and recover benefit payments obtained by deceit or misrepresentation

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Aetna Special Investigations Unit

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  1. Aetna Special Investigations Unit Alaska Health Care Commission June 19-20, 2014

  2. Mission and Purpose • To effectively detect, investigate, and prevent health care fraud & abuse and recover benefit payments obtained by deceit or misrepresentation • To comply with state and federal regulations concerning anti-fraud plans and fraud reporting • To satisfy Aetna’s fiduciary responsibilities to its customers while leading the industry in combating health care fraud. Detection Investigation Prevention Reporting, Education & Compliance Recovery SIU Focus Areas – Fraud and Abuse • Detection – Proactive data analysis identifies providers of interest based on behavior within peer group. • Investigation – Thoroughly explore all of a provider’s billing/practice behavior, not just a single issue. • Recovery – Work directly with providers to understand/educate and/or pursue recovery • Reporting, Education & Compliance – Operational and financial results reporting; mandatory anti-fraud training for employees, business associates and delegates; mandated state and federal fraud reporting • Prevention – Pre-payment claim review and routing avoids fraudulent payments Major Activities

  3. Staffing • Special Investigations Director • Medical Director • Investigative Managers • Investigative Team Leaders • Investigators • Clerical/Administrative • SIU Investigative Analysts (Field) • Info. Mgmt / Fraud Intelligence Team • TOTAL STAFF 131

  4. Current Schemes

  5. Source of Cases • Internal, customer service, patient mgmt., etc. • Delegates, subsidiaries and business associates • NHCAA/other insurance companies • Law Enforcement/Subpoena • Telephone Hotline, service E-Mail • Fraud & Abuse Management System (FAMS) • Outside law firms

  6. 2013 Metrics • Savings & Recoveries - $300 million • Cases received – 1,800 • Case inventory – 25,000 • Alaska experience – 5 cases; 3 provider & 2 member • 2014 Alaska open cases – 1 provider & 1 member

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