Aetna Special Investigations Unit

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Aetna Special Investigations Unit

• Alaska Health Care Commission
• June 19-20, 2014

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SIU Focus Areas Fraud and Abuse
Major Activities

• Detection Proactive data analysis identifies
  providers of interest based on behavior within
  peer group.
• Investigation Thoroughly explore all of a
  providers billing/practice behavior, not just a
  single issue.
• Recovery Work directly with providers to
  understand/educate and/or pursue recovery
• Reporting, Education Compliance Operational
  and financial results reporting mandatory
  anti-fraud training for employees, business
  associates and delegates mandated state and
  federal fraud reporting
• Prevention Pre-payment claim review and routing
  avoids fraudulent payments

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Staffing

• Special Investigations Director
• Medical Director
• Investigative Managers
  
• Investigative Team Leaders
• Investigators
  
• Clerical/Administrative
• SIU Investigative Analysts (Field)
• Info. Mgmt / Fraud Intelligence Team
• TOTAL STAFF 131

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Current Schemes
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Source of Cases

• Internal, customer service, patient mgmt., etc.
• Delegates, subsidiaries and business associates
• NHCAA/other insurance companies
• Law Enforcement/Subpoena
• Telephone Hotline, service E-Mail
• Fraud Abuse Management System (FAMS)
• Outside law firms

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2013 Metrics

• Savings Recoveries - 300 million
• Cases received 1,800
• Case inventory 25,000
• Alaska experience 5 cases 3 provider 2
  member
• 2014 Alaska open cases 1 provider 1 member