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HCF Investigator Assumptions - *General knowledge of the Health care Delivery System *Health plan policy and procedures relative to the delivery of services *Able to identify Red Flags, behaviors & indicators of health care fraud schemes Know applicable federal & state laws related to health care fraud *Law enforcement & regulatory agencies that have oversight responsibilities for HCF *Local & regional investigative groups that have similar interests Fraud, by it's very nature, is decptive. - As such, nobody really knows what the impact and cost of fraud is. However there are some common industry estimates Conservative US Healthcare spending in 2015 was $3.2Trillion Conservative estimate of fraud is 3-5% (means tens of billions of dollars each year) Estimate of $96 billion -> $320 Billion / year (if we estimate between 5% and 10%) Anatomy of an investigation - Each fraud case is unique, however, under the surface of the specific schemes, all HCF investigatons have a common structure, or process. Anatomy of an investigation - 1) Detection - The process of uncovering potential fraud waste and abuse utilizing human and technical resources and techniquesAnatomy of an investigation - 2) Assessment - The primary objective of the assessment phase is to establish PREDICATION for the continued investigation