Question

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?

Answer 1

1. ANS: In order to prevent fraud it is necessary to use the postal office payment addresses that are adequately stocked with dental chairs as well as a reception area. Thus, through the use of the dental offices instead of the payment addresses It will not be easy to detect fraud because this will affect the billing scheme since some of the employees may use false documentation to manipulate the organization’s billing system which in the long run may generate a false payment made by for their own benefit. For instance, in the dental offices, a fraudster may create some fictitious vendors that may bill the organization for payments. In essence, this can also be achieved by using a fake name as well as a post office box.

2. ANS: It is true that real dentists may send claims to various different firms. However, since the organization represents just some few firms, the sequential number of sheets from the specific dentists may pass through many organizations that the dentists are working with. However, through viewing the records, it is apparent that some are sending sequential claims. However, it necessary to ensure that when a claim is submitted, it is necessary to process it through a series of edits in order to ensure that the data that is submitted on the claims are complete and correct. Nevertheless, when the claims are incorrect or having some missing information, they may be returned to a return provider to make sure that the file is correct. On the other hand, since the dental organizations billing transactions may encounter different edits while processing the claims, the adjustments may need correction more than one time or for various reasons. Hence, it is necessary to verify all the necessary claim data that are present and that the data presented is complete and correct before being submitted to the billing transactions.

3. ANS: From the information and data obtained from the claim list and after determining the total number of cavities for each patient, it is apparent that the patients are visiting the dentists regularly. But there are other activities, such as cleaning which is done most often than other forms of services. However, to prevent embezzlement, recording all the dentists activities is important and this should be coupled with monitoring the system at random, since the dentist may consider regular scheduled audit in order to detect theft, and such audits may be effective. In addition, the audits should be conducted at intervals by requesting the dentists practice records, as well as monitoring of the ay sheets as well as bank deposit slips.