February 10, 2020
DATE: April 9, 2020
TIME: 3:00 pm – 5:00 pm
LOCATION: Hyatt Regency Monterey Hotel And Spa On Del Monte Golf Course, Monterey, CA
Beth Howard-Stalker, CEO of CostFirst, and Bill Reynolds of FirstI, will be speaking on the topic of Unbundling Schemes in medical coding at the upcoming Anti-Fraud Conference in Monterey, CA. Not unlike police officers becoming familiar with the vehicle code or penal code in order to effectively do their jobs, those involved with insurance or medical fraud must understand the complexities behind medical bill coding. More importantly, the nexus between the codes used by a provider and the medical necessity of the treatment provided can help identify medical fraud. The course will center on identifying medical necessity through the relationship of billing codes, e.g. Current Procedural Terminology, ICD-9 CM/ICD-10, and HCPCS, with the medical record.
February 4, 2020
First Investigation Services (FirstI), a leader in medical provider and billing investigations, has announced a new program called SHIELD™ designed to proactively protect medical claim portfolios. By using proprietary (patent pending) data analytics, SHIELD goes far beyond the customary California Department of Industrial Relations (DIR) listings of suspended and stayed medical providers. SHIELD is driven by HEAT™ software, and when integrated with a medical portfolio database, it has unique identifiers that will recognize providers that are indicted, criminally charged, suspended, or have controlling interests other entities.
According to Wil Kiesel, Director of Business Development and Account Management, “Our SHIELD+HEAT™ software solution is so effective it can also detect providers that have already been criminally charged, before the DIR declaration. By applying our SHIELD solution in any bill review, MPN, or lien program, our clients avoid paying providers needlessly while also strengthening their position for both negotiations and litigation.”
“The results speak for themselves,” according to Beth Howard Stalker, CEO of CostFirst, a lien resolution and bill review company. “In 2019 we’ve found in our lien program results that the DIR list only accounted for 129 suspended and stayed providers vetted in our CUBE system. Our SHIELD+HEAT solution identified 1,227 non-qualified providers, nearly ten times as many. The real benefits for our clients come in the gross savings on liens—$1,817,876.20 from the DIR list and $9,180,177.92 based on our SHIELD+HEAT solution. We look forward in applying this program in bill review platforms for employers. It will not only yield in tremendous savings on medical claims but will also minimize risks in liability.”
Michael E. Lents, COO of CostFirst, has stated that his team has applied the SHIELD+HEAT program into their litigation and has prevailed on numerous occasions proving that a suspended provider was an officer of an entity attempting to collect on its liens. The judges found that although the entity was not on the DIR list, it should be on stay pursuant to Labor Code section 4615. In fact, one case was upheld by the Appeals Board.
August 8, 2019
Jacquelyn Castro v. Chipotle Mexican Grill; ADJ10441959
Dr. Kevin Do was a Director of North Valley Diagnostics at the time the services were rendered to the applicant, and Dr. Kevin Do has been suspended from the workers’ compensation system. Furthermore, an adverse inference per Rule 10622 was warranted for lien claimant’s failure to comply with a subpoena for corporate records. CostFirst, working in tandem with FirstI’s investigation utilizing the SHIELD™ program, was awarded the decision to stay the lien of North Valley Diagnostics, pursuant to Labor Code § 4615. (Suspended physician was Director of corporation, lien therefore stayed.)
FirstI’s SHIELD™ program successfully identified a non-qualified provider that was not identified on DIR list. SHIELD is designed to proactively protect their clients’ medical claim portfolios by using proprietary (patent pending) data analytics. SHIELD goes far beyond the customary DIR listings by using unique identifiers that will recognize providers that are indicted, criminally charged, suspended, or have controlling interests in another entity.
Billion-Dollar Surgery Scam
July 1, 2019
Bill Reynolds and Mark Sersansie first learned about one of the most outrageous medical frauds in California history nearly a decade ago. Together the men discovered an illegal scheme, where middlemen were paid to find patients who had back problems stemming from work-related injuries and doctors were paid kickbacks to perform the spinal surgeries at specific hospitals. Ultimately, the two men would learn that hospitals were not only overbilling for the spinal hardware but, in many instances, dangerous counterfeit hardware was implanted into the backs of innocent people. There has been a federal criminal investigation into the scam, called “Operation Spinal Cap,” and the Department of Justice has said the fraudulent claims related to this scheme span a 15-year period and cumulatively total more than $950 million. The scheme involved $40 million in illegal kickbacks paid to doctors and other medical professionals in exchange for referring thousands of patients for surgeries at California hospitals.
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