You landed a summer internship with a company that processes dental insurance claims for insurance companies. The company receives the insurance claims from dental offices, achieves authorization from the correct insurance company, and sends payment checks. You do not deal with dental customers directly; instead, you work with insurance companies on one side and dental offices on the other. After two months with the company, you think a number of frauds may be occurring, and you feel the best way to search for these frauds is to investigate documentary evidence. Because hundreds of dental offices send insurance claims to your office, some may not be real dental offices. You contact the IT department and receive a set of files that represent the documents involved in transactions for the past three months.
You will conduct an investigation toward answering the questions below. You will be considered for testimony as an expert witness. You will prepare a report for the Court of your findings and will also prepare and submit with your report a resume outlining your experience and credentials that make you an expert in your field.
Questions:
Some dental offices may not employ real dentists and may be front companies that are sending claims out for work not performed. A real dental office should have a real office address with dental chairs, reception areas, etc. Are any dental offices instead using post office boxes in their payment addresses?
Real dentists should be sending claims to many different insurance companies. Since your company only represents a few of these companies, the sequential numbers on the claim sheets from a given dentist will rotate through all of the companies that the dentist is working with. If the numbers sent to you from a given dentist are sequential, you know that the dentist is only sending claims to you. Search the claims file for sequential numbers from any given dental office. Are any sending you sequential claims?
A human adult has 32 permanent teeth. Your company requires that each claim list the patient seen (identified by patient ID), the tooth worked on, and the type of work done. Because of the natural limitation on the amount of cavities that could be filled on any one person, it is rare that a person would have more than a few cavities in the three months of your audit (it is possible for a tooth to have more than one cavity). Using this field, calculate the total number of cavities submitted for each patient. Do any patients seem to be visiting the dentist too often?