8 Fraud Scope Use Cases: Uncovering FWA Across Professional, Facility, Pharmacy and Dental Data

During Codoxo’s second annual Customer Conference, Codoxo experts demonstrated Fraud Scope’s ability to analyze all data types and quickly identify new schemes for investigation. 

As part of Codoxo’s award-winning Unified Cost Containment platform, Fraud Scope is an end-to-end fraud, waste, and abuse (FWA) solution that uses advanced and proprietary AI technology to quickly and accurately detect fraud, waste, and abuse while providing SIU and PI teams with fully automated case and lead workflows. Fraud Scope helps health plans, healthcare agencies, and PBM teams stay ahead of evolving threats by identifying and flagging emerging schemes for rapid review and intervention. Fraud Scope’s rapid review and intervention capabilities are a game-changer to control costs and protect the bottom line. 

These use cases and best practices highlight how Fraud Scope’s intuitive workflows and user interface can quickly alert SIU and payment integrity team members to situations that warrant a deeper look. Its suite of AI detectors, user-driven query toolkit, and monitoring interface – combined with the depth of our partner’s business intelligence – allows users to validate findings further for immediate or future action.  

Use Case #1: The Overbilling Allergist 

Fraud Scope’s ability to analyze professional data and quantify how likely it is for providers to exhibit behaviors or coding practices that don’t align with their peers’ performance helps PI or SIU teams stay ahead of outlier behavior and excessive billing. For example, in one particular case, a provider earned a high-risk score for his abnormal billing patterns and excessive allergy testing. Both were flagged in his profile. 

Certain treatments performed by this doctor also raised suspicion. For example, his allergy injections peaked in October, however this treatment is typically far more common in other months. He also consistently billed allergy injections and testing with implausibly high units in very short periods of time. Because the units of service are similar and close together, this provider is likely intentionally bypassing an edit he knows is in place.

Another red flag? Most of this provider’s billing included allergy serum preparation and allergy testing codes with very few modifiers. This indicates a potential lack of the specificity that’s necessary in billing. 

This doctor targeted specific procedures repeatedly, leading to inflated billing. Depending on the plan’s policies, this may be a viable lead for a PI team or an SIU.

Use Case #2: The Provider With a High Paid-Per-Patient Values 

When reviewing  professional data at a summary level, analysts, investigators, and clinical staff can identify strong signals for potential FWA when a provider repeatedly uses a specific code for one patient or a small group of patients. In these instances, the claim lines or units of services-per-patient ratios skyrocket, which lead to higher payments per patient.  

In this case, Fraud Scope’s Query Aggregate Tool detected an alarming discrepancy in the code usage of a behavioral healthcare provider, demonstrating that this clinician had substantially higher paid-per-patient totals and services-per-patient ratios compared to their peers, which raised suspicions of over utilization. The user also applied thresholds around paid-per-patient totals and line counts to ensure the results contained reasonable starting values to warrant further review.  

By leveraging the Fraud Scope Query Aggregates tool, SIU or utilization review teams can easily identify activity that indicates potential abuse or waste – without narrowing their research to a specific provider or procedure code  – empowering them to make a decision to monitor the provider or take further action. 

Use Case #3: The Medical Center With Shortened Stays 

Using facility data, Fraud Scope’s Suspicious Trends Detector flagged a medical center’s length of stay for a specific Diagnosis-Related Group (DRG) was lower compared to their peer group. 

The peer percentage detector value was 97.1%. – which means, 97.1% of providers have longer stays than this particular medical center. Such a notable deviation raises a red flag for patient length of stay analysis. 

After examining individual claims for that DRG group, which required a minimum four-day inpatient stay, the team found several corrected claims—including one with a three-day stay. Analysts also found claims with unusual discharge statuses, such as patients leaving the facility against medical advice after just two days. Why did this stand out? One patient was allegedly on a ventilator, making that scenario impossible, which raised additional suspicions regarding short-stays and discharge practices at this facility. 

Of interest, this facility has more corrected claims, i,e, type of bill 117 compared to the final  claims, i.e. type of bill 111. Out of 25 claims, nine met the minimum requirement. However, two outliers prompted a deeper dive and the team focused its efforts on determining why the facility repeatedly submitted corrected claims with length-of-stay discrepancies.

Uses Case #4: Suspicious Sequencing 

To maximize reimbursement, some facilities manipulate the order of diagnoses, designating a different condition as the primary diagnosis than what actually brought the patient to the facility. In this case, a Fraud Scope user found a complication code was placed as the principal diagnosis with sepsis added as a secondary code—when it clearly should have been the primary. This finding indicates a problem with sequencing, and that the facility could be manipulating codes to get higher reimbursement. 

Fraud Scope harnesses Present on Admission (POA) business intelligence which plays a significant role in spotting this scheme. It indicates whether conditions were present when the patient was admitted. For example, if sepsis wasn’t shown as present on admission but was recorded as such, it’s a signal that inaccurate reporting could lead to improper Major Complication or Comorbidity (MCC) assignments. 

The team also noted Clinical Documentation Improvement (CDI) programs may have been sending inappropriate queries to physicians to add specific diagnoses, such as sepsis unspecified, to claims. This is an inappropriate application of MCC codes that results in higher payments than warranted.  

Fraud Scope also found instances where MCCs like acute diastolic congestive heart failure and acute respiratory distress syndrome were consistently applied to a large percentage of cases. These types of inappropriate billing practices can lead to significant overpayments. Fraud Scope assists facility review teams with identifying these instances and adding the claims to their facility audit, if warranted.  

Use Case #5: A Pharmacy With Suspicious Patient Count to Claim Count 

While working within Pharmacy data and using Fraud Scope’s Suspicious Trends filter, an analyst noticed discrepancies in the patient count to claim count ratio, particularly for one drug, which was more than seven times or seven prescriptions to every one patient. 

To get more information, the team filtered the data in Fraud Scope to determine how many patients were receiving more than 365 tablets of the drug in a year. The resulting number was suspiciously high. Not only were excessive quantities of the drug being dispensed, but the team also noticed unusually high co-pays. Armed with this information, they decided to dig a little deeper into the pharmacy’s practices. 

Looking across a four-year timeframe, they noticed a patient with 56 fills in two years. Patients should only have 12 fills a year for this particular drug. This patient’s claims chart displayed inconsistencies with the dates and number of pills in each prescription with the patient filling the prescription three times in March alone. The excessive prescription fills supplied the patient with more than 120 pills—another indication of suspicious behavior that prompted further investigation into the pharmacy. 

Use Case #6: Missing Medical Claims

Fraud Scope identified an emergency medicine physician who submitted significantly more claims than his peers. In fact, this provider had 951 claims (without supporting medical claims) compared to an average of 38.8 claims without supporting medical claims by his peers. After looking into this doctor, the team found he was one of the higher paid physicians, bringing in almost a quarter of a million dollars a year. 

While he charged appropriately for his services, his average charge per patient and average pay per line were low. Why does that matter? It indicates a high volume of low dollar claims. Further analysis showed this doctor is mostly prescribing HIV-related medications. 

After analyzing the data, the team delved deeper into the pharmacy responsible for filling the prescriptions. Fraud Scope was utilized to pinpoint concerning trends in the dispensing of the two HIV drugs that the doctor had ordered. Specifically, the team discovered that June had been an extremely active period, with the pharmacy dispensing over 80 bottles of the medication in a single day – a highly suspicious occurrence that warranted further review. 

The team then filtered the data to see how many patients received a year’s supply in a shorter timeframe and questioned the necessity of those refills. In some cases, patients were receiving up to 480 pills a year, when they should only have 365. That led to a few key questions: Is the pharmacy using overrides to allow this to go through? Is the pharmacy shorting them?

The team also noticed that several female patients were prescribed one of the drugs, even though it wasn’t FDA approved for females – raising concerns and serving as another reason for further investigation. 

When prescribing these medications to treat patients with HIV, essential testing and lab work must be completed as well. For example, to keep taking one of the drugs, patients need to be tested every three months to make sure they’re HIV negative. If there aren’t any medical claims for these tests to go along with the prescriptions, it’s another red flag and worthy of a deeper dive by an SIU or clinical team. 

Fraud Scope looks for medical claims at least 60 days before the written date of the pharmacy claim. If there are no medical claims within 60 days before the written date, it will be flagged in Fraud Scope’s detector.  

Use Case #7: A Dentist With Concerning Billing Habits 

The dental industry is also significantly impacted by FWA, with more than $12.5 billion, or 5%, of the $250 billion industry lost each year.

In the case of one general dentist, Fraud Scope identified several red flags within his billing practices when analyzing dental data. The first flag identified was in coding. Unlike this dentist’s peers, this provider often used an impacted tooth removal code. What makes this suspicious? Most general dentists don’t perform tooth extractions.

Wisdom teeth extraction is an example of an impacted tooth removal, which usually occurs during the late teenage or young adulthood years between the ages of 17 and 25. However, concerns were raised regarding the age of the patients seen by this particular doctor. Upon further investigation with the assistance of the Fraud Scope’s advanced graphs and charts, it was found that the majority of the doctor’s patients were at least 60 years of age. 

Upon examining the situation further, it was found that the dentist in question had been extracting far fewer teeth than is typical in one sitting. Rather than extracting the customary four teeth at once, he only removed one or two at a time. Additionally, the procedure codes showed a complete absence of anesthesia administration for any of the extractions, which is a necessary and expected element of tooth removal.  

With so many red flags uncovered by Fraud Scope, analysts added this doctor to Fraud Scope’s Watchlist for future review by an SIU or payment integrity team, if warranted. 

Use Case #8: Chiropractors Who Practice Upcoding

Some providers that are trying to “improve their bottom line” might submit claims with codes for services that are more expensive than what was actually provided—a common form of FWA. Fraud Scope helps identify these upcoding schemes  via detectors across all specialties and in this case, specifically for chiropractors. 

Fraud Scope’s detector analyzes the overall utilization of an upcoding set across the peer group and then identifies providers whose utilization is significantly different compared to their peers as well as concentrated on the code with the highest relative value unit (RVU). Fraud Scope also makes it easy to review provider summary metrics, which offer valuable insights. Users choose the metrics they’re most interested in and Fraud Scope then creates a chart of where everyone in the peer group falls.  

In this case, Fraud Scope reported that the provider used the high-cost 98942 code 78% of the time, the largest percentage in the peer group. The software also looked at how the practice’s pay-per-patient perspective compared. What did it find? A higher patient volume. When Fraud Scope sorted this code by start date and patient ID, it showed the same patient ID and codes used more than once on the same day—another red flag. 

In general, this provider’s services skewed significantly more to the most expensive service, with a higher total amount paid to the practice than most peers, indicating a potential FWA problem. 

These types of metrics provide valuable insights into where potential risk lies, and helps payment integrity teams determine which flagged providers warrant closer monitoring. Users of Fraud Scope can leverage various searching tools and methods to identify signs of upcoding based on preference. And because Fraud Scope only flags paid claims, it’s all actionable. 

Stay Ahead of FWA Threat

Our Customer Conference sessions highlighting Fraud Scope use cases demonstrated many ways Codoxo’s proprietary AI technology can quickly identify FWA across all claim types. With automated cases and lead workflows, SIU and Payment Integrity teams can stay ahead of evolving threats and intervene when necessary, significantly reducing the costs and problems associated with such schemes and ensure greater payment integrity. 

As Codoxo’s flagship product, Fraud Scope is integrated into Codoxo’s award-winning AI-powered Unified Cost Containment platform and delivers a guaranteed 15x ROI. If you’d like to learn how Fraud Scope can help you automatically and accurately detect existing and emerging threats to take total control over costs, please contact us at info@codoxo.com.