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A healthcare fraud investigation can originate from many different sources. Often, it begins with a tip received from a member or an unusual pattern noticed in the claims data. But whatever the source, building a successful case to then turn over to law enforcement for investigation and potential prosecution requires an extremely careful, thorough, and extensive process of data analysis.
With more than 2.5 million members and over 40 million claims processed each year, one Minnesota health plan knows this challenge well, and is committed to limiting fraud, waste, and abuse (FWA) across its network to ensure its members receive high-quality, medically necessary care at a fair price. So when the plan received a tip from a member on its special investigative unit (SIU) fraud hotline, alerting them to a chiropractor potentially billing for services not rendered, it acted quickly to start building a case.