Data Driven Fraud Assignment Dental Insurance Fraud You landed a summer internship with a company that processes dental insurance claims for insurance companies The company receives the insurance claims from the dental office where the patient had the work performed, achieves authorization from the correct insurance company, and sends payment checks to the dentist You do not deal with the patients 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 Ch 08 dentists Ch08 claims Ch08 patients Some dental offices may not employ real dentists and may be front companies that are sending claims for work not performed A real dental office needs a physical address with dental chairs, reception areas, etc Do any dental offices have addresses that might indicate they are front companies 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 the companies that 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 Are any of the claim number sequences suspicious A human adult has 32 permanent teeth Your company requires that each claim list the patient seen, the tooth worked on, and the type of work done Do any patients seem to be visiting the patient too often Patients normally need to live close to their dentists because receiving service requires a visit to the office Do any patients seem to have a long drive to their dentists' offices

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Data Driven Fraud Assignment: Dental Insurance Fraud You landed a summer internship with a company that processes dental insurance claims for insurance companies. The company

Data Driven Fraud Assignment: Dental Insurance Fraud

You landed a summer internship with a company that processes dental insurance claims for insurance companies. The company receives the insurance claims from the dental office where the patient had the work performed, achieves authorization from the correct insurance company, and sends payment checks to the dentist. You do not deal with the patients 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:

Ch-08_dentists

Ch08_claims

Ch08_patients

Some dental offices may not employ real dentists and may be front companies that are sending claims for work not performed. A real dental office needs a physical address with dental chairs, reception areas, etc. Do any dental offices have addresses that might indicate they are front companies?
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 the companies that 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. Are any of the claim number sequences suspicious?
A human adult has 32 permanent teeth. Your company requires that each claim list the patient seen, the tooth worked on, and the type of work done. Do any patients seem to be visiting the patient too often?
Patients normally need to live close to their dentists because receiving service requires a visit to the office. Do any patients seem to have a long drive to their dentists' offices?