Impact in Action
Explore how Healthcare Fraud Shield helps organizations identify and prevent FWAE through real-world case studies. Our expertise supports clients in tackling complex challenges and achieving compliance across the healthcare payer market.
Client Success Snapshots
$2.9M
In Savings
Billing Blunder
Service Misrepresentation: A provider was flagged for billing office visits when COVID-19 tests were actually conducted at home or drive-thru sites.
Wider Pattern: Further investigation uncovered other entities engaged in similar billing practices.
Medical Record Review: Documentation revealed cloned records, contradictions, and missing support for evaluation and management services.
Financial Impact: An $835K overpayment was identified, emphasizing the need for rigorous review and accountability in billing practices.
$1.8M
In Savings
Fabricated Files
Unusual Payment Spike: PostShield detected a $1.5 million payment increase over 15 months at a facility.
Employee Tip: A former employee reported that false medical records were being created to justify residential services.
Wider Investigation: Other connected facilities were also under scrutiny for similar practices.
Key Findings: Investigators uncovered fee-forgiving, misrepresentation of services, and billing for services not provided.
Action Taken: A flag was issued on the provider, leading to a $247.5K settlement and prepay savings.
$1.6M
In Savings
Authorization Absent
Unusual payment spike: The facility was flagged for a spike in home health care services, as well as a spike in payment per member.
Wider Pattern: The facility was noted as billing direct nursing services by an RN on 97% of claims while nursing services by an LPN was extremely limited. Some patients were also billed for over 12 hours in a day.
Wider Investigation: The facility was noted as submitting claims without prior authorizations.
Financial Impact: In addition to the prevented loss, a settlement of $1.5 million was reached with the facility.
$1M
In Savings
in <5 months
Risky Residential Revenues
Potential Fraud: Providers were flagged for billing for adolescent residential facilities services in one state one day and another the next day.
Wider Pattern: Ongoing investigations has revealed hotbed locations for patient brokering; in one state one day and another the next.
Medical Record Review: Claims have been denied to request records, but no records have been provided to date.
Financial Impact: Savings occur on the front-end, avoiding retrospective pay and chase efforts. To date, trending towards >$1m in savings and cost avoidance realized in just under 5 months.
$920K
In Savings
Injection Irregularities
Risk & Payment Spike: PostShield flagged a provider for concerning trends in testosterone and B-12 injection billing for decreased libido and malaise.
Questionable Billing Practices: The provider heavily used modifier -25 with evaluation and management services.
Medical Record Review: Documentation failed to support the billed services.
Settlement Reached: After investigation, the provider settled for $360K, addressing discrepancies and preventing further losses.
$510K
In Savings
Derelict DME
Unusual payment spike: Supplier flagged on a spike in revenue, driven by payments for bi-PAP devices.
Wider Pattern: Supplier also flagged on non-covered services (C/BiPAP) and MUE concerns. Compared to peers, supplier served fewer patients but had the highest cost per patient in the peer group.
Medical Record Review: All claims reviewed exhibited issues including supplies not supported by documentation, no proof of delivery or other missing documentation, including prescriber records.
Financial Impact: In addition to the prevented loss and savings, $80K in recoveries have been received from the provider.