AdvanceMed: CSC Combats Healthcare Fraud

Medicare fraud costs the U.S. government billions of dollars a year, and a CSC company is working in the trenches to fight it. AdvanceMed, a wholly owned CSC subsidiary, provides investigative services that support law enforcement efforts to catch and prosecute healthcare fraudsters.

AdvanceMed's team of more than 200 professionals blends CSC’s healthcare expertise with the company’s technical know-how. Staff members include doctors, nurses, data analysts and investigative specialists, such as former FBI agents. Their goal: Identify and eliminate healthcare fraud, waste and abuse. The company also helps organizations improve the overall integrity of their health and pharmacy programs.

A large portion of AdvanceMed’s business is with the Centers for Medicare and Medicaid Services (CMS). Working under the CMS’s Program Safeguard Contract (PSC), AdvanceMed battles healthcare fraud in 23 states across the United States. In doing so, AdvanceMed performs a wide range of forensic functions and works closely with law enforcement agencies at all levels.

CSI: CSC

Nailing down crooked providers requires detailed detective work. Phyllis Kay, AdvanceMed’s director of operations, says, "We serve an important support function in terms of putting together cases by going out and doing on-site investigations of providers." AdvanceMed’s tasks include looking for patterns of aberrant billing by providers who may be trying to cheat the system. Staffers also serve as expert witnesses in court cases.

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Kay says CSC’s federal government and healthcare industry experience has helped AdvanceMed develop a robust investigation process. "The professional skills of different types of people — clinical, policy and IT — come together as a team." She adds that AdvanceMed’s antifraud efforts benefit from the close partnership her team has developed with the CMS.

Busting a dishonest doctor

A good example of AdvanceMed at work is the role the investigative team played in the successful prosecution of Dr. Jorge Martinez, an anesthesiologist in Ohio. Dr. Martinez wrote an inordinate number of prescriptions for pain pills and billed various agencies, including Medicare, for a large number of unneeded nerve block injections. He racked up tens of millions of dollars in fraudulent billings and two patients died as a result of his inappropriate actions.

AdvanceMed was part of the investigative team that meticulously built the government’s case against Dr. Martinez. To bolster the case, AdvanceMed conducted exhaustive reviews of medical records and interviewed some of the doctor’s patients. A peer-comparison statistical analysis confirmed that the rogue doctor was prescribing far more medications than his peers and administering more pain relief injections than were necessary.

Eventually, Dr. Martinez was convicted on 56 counts of healthcare fraud and sentenced to life in prison. AdvanceMed was part of the team that received the 2006 Investigation of the Year Award from the National Health Care Anti-Fraud Association in recognition of their work on the case.

Advanced tools and techniques

The AdvanceMed staff leverages CSC’s technical expertise to process and analyze massive amounts of Medicare claims data. The company’s technical team includes IT and data professionals charged with making sure Medicare information from various sources is properly processed and stored.

"We have some very sophisticated tools and techniques," says Frank Armiger, program director of AdvanceMed’s PSC initiative. "Through the use of large data warehouses and data mining, we have transformed our mission from a very reactive approach to a very proactive approach."

Armiger adds, "We’ve moved one step further by trying to identify the fraud before the claims are paid so the money doesn’t get out the door, then have to be chased after."

To preserve and protect

While AdvanceMed's chief focus is on fighting fraud, the company also offers services aimed at preserving the overall integrity of healthcare information. For example, AdvanceMed serves as the medical review contractor for the CMS’s Comprehensive Error Rate Testing Program. With the goal of improving the Medicare claims process, the program measures error rates in medical claims and the data is used to establish performance standards.

"The focus here is on helping Medicare providers with the actual filing of their claims," Kay says. "In addition to helping identify errors, we help the CMS educate providers on how to improve the filing of Medicare claims so they’ll be correct the first time."

AdvanceMed’s capabilities also include medical record management, healthcare data management and healthcare-related IT support solutions.

The sprawling Medicare system will always be a desirable target for unscrupulous healthcare providers. Still, Kay and her team feel they are making progress against the bad guys. "AdvanceMed aims to help protect the elderly population from fraud, protect the Medicare trust fund, and ultimately, protect taxpayers’ dollars," concludes Kay.