Category Archive: Healthcare

Learning analytics identify human technology

Analytics are more than Numbers and Stats – It’s About People by Tammy Marple, VP – Special Investigations Unit

August 7, 2018

During my time as a fraud analyst, I realized that my work was so much more than just numbers and statistics. I worked in State Government for many years and a few years ago, my manager asked me to conduct a study on Opioids. I lived that assignment for 18 months. After the Opioid study […]

Ambulette Fraud

March 28, 2018

“Ambulette” is a term to describe the vans and cars that transport Medicaid patients to non-emergency appointments. Despite the presence of ambulettes, millions of Americans continue to miss medical appointments each year because of transportation problems. One possible answer to this problem? Rideshare companies like Uber and Lyft who sign agreements with hospitals and medical […]

An “Amazing” Contributor to the Nation’s Opioid Crisis

February 26, 2018

The Sacramento Bee, my local newspaper, reported this week on an area doctor, a seemingly successful cardiologist and graduate of Northwestern’s medical school, who plead guilty and was sentenced to 52 months for illegally prescribing opioids. After reading about Doctor Capos’s crimes, 52 months seems grossly inadequate. The sentencing judge agreed, despite acknowledging the doctor’s […]

A New Way to Rip Off the Taxpayer

February 23, 2018

I often mention how “impressed” I am by the ingenuity of fraudsters and their ability to find new and creative ways to steal money. And now, with the country starting to pay attention to the opioid crisis, comes word of one of these fraud innovations. This time, fraud (and to be fair, often just massive […]

Social Security Fraudster Captured in Honduras

December 13, 2017

Several months ago, we wrote a post about the self-proclaimed “Mr. Social Security”, Kentucky attorney Eric Conn, who fled prosecutors in the face of a 12-year prison sentence. Conn had concocted a scheme where he bribed a judge and a psychologist to defraud the Social Security Administration out of $550 million. The colorful Mr. Conn […]

Ebola Relief Fraud

November 13, 2017

As a country, we have become accustomed to reading stories about fraud in healthcare, financial services, and government programs. It doesn’t make it right, but it’s certainly not new. Now though, news comes from the American Red Cross that $5 million of Ebola relief funds were fraudulently disbursed on overpriced supplies, fake customs bills, and […]

A Reminder of Government’s Important Role in Helping Americans

October 30, 2017

Regular readers of this blog know that we often focus our comments on the fraud and abuses in government subsidy programs. Our intent is almost always to point out solutions that can make these programs more effective, rather than to question the existence of the programs altogether. In fact, most Pondera employees worked for government […]

Disturbing Reports of Dentists Committing Medicaid Fraud

October 4, 2017

A recent spate of high profile arrests of dentists is drawing attention to an often-overlooked segment of Medicaid fraud. Some unscrupulous dentists are exploiting gaps between what private insurers reimburse versus what Medicaid will pay for. Others are just brazenly breaking the law to rip off state Medicaid programs. Consider these recent charges brought against […]

$1.5 Million to Clip Toenails?

September 9, 2017

While I don’t think healthcare fraud is a particularly humorous subject, a recent case in Florida does lead to a few chuckles. Earlier this year, a Northern Florida doctor pled guilty to falsely billing over $1.5 million to Medicare and TRICARE. The billings were submitted for a complex procedure that required the removal of skin […]

Does the Mylan EpiPen Settlement Send the Wrong Message to Fraudsters?

August 23, 2017

The United States government and several states recently announced that they had settled a $465 million lawsuit against Mylan Inc., the maker of the EpiPen. The Department of Justice stated that Mylan had “knowingly” misidentified the EpiPens as generic to reduce the number of rebates it owed to state Medicaid programs. All drug manufacturers, including […]