Category Archive: Medicaid


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 […]

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A New Way to Rip Off the Taxpayer

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 […]

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$1.5 Million to Clip Toenails?

$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 […]

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

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 […]

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37 States Targeting Elder Abuse

37 States Targeting Elder Abuse

June 27, 2017

Regular readers of our blog know that Pondera has strong feelings about the need to protect the elderly from abuses while they are being cared for in facilities and their homes. In fact, in April of this year we wrote about the devastating abuses in nursing homes that continue to plague the elderly. Now, a […]

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New Data on Problematic Government Programs

New Data on Problematic Government Programs

May 3, 2017

One of my favorite websites, paymentaccuracy.gov, has received a number of updates which may provide some insight into the current administration’s priorities. If you haven’t done so already, I encourage you to visit the site as it provides improper payment information on the government’s high-priority programs: those that report over $750 million of improper payments […]

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Disturbing Reports of Nursing Home Abuse

Disturbing Reports of Nursing Home Abuse

April 24, 2017

Last month CNN published a horrifying report on sexual abuse in America’s nursing homes and assisted living facilities. The report provided details on dozens of assaults, rapes, and other incidents that, quite frankly, were extremely difficult to read. In my opinion, however, this level of detail is probably necessary to shock people into taking action […]

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Changes to Government Healthcare

Changes to Government Healthcare

November 16, 2016

As a company, Pondera is closely following the comments coming from the incoming administration about how they are approaching government efficiency and entitlement reform. Paul Ryan, in particular, has made several statements about the Affordable Care Act (Obamacare), Medicare, and Medicaid. This post provides some of our thoughts around how these changes may affect fraud, […]

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Provider Screening and Program Integrity in Medicaid Managed Care

Provider Screening and Program Integrity in Medicaid Managed Care

June 13, 2016

Medicaid expenditures have nearly doubled over the last decade [1] and states have increasingly looked to a capitated reimbursement model utilizing managed care organizations (MCO) to ensure continued access to quality health care services. The Centers for Medicare and Medicaid Services (CMS) estimate that roughly 80% of all Medicaid recipients currently receive healthcare services via […]

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