FWA Detection
🛡️ Public data only — no PHI permitted on this instance.
Fraud / Waste / Abuse Detection
Billing anomaly surveillance · upcoding risk · Stark/AKS referral patterns · claim fingerprints · geographic anomalies · compliance events — 1,705 corpus deals
Total Anomalies
29
High Severity
9
Total Exposure
$17.5M
FWA Risk Score
100/100
Risk Tier
ELEVATED
Upcoding CPTs
8
Compliance Events
5
Corpus Deals
1,705
FWA Risk Posture
Risk tier: ELEVATED · 29 anomalies · $17.5M total exposure
9 high-severity flags warrant immediate compliance review
Provider-Level Billing Anomalies
| Provider | Specialty | Pattern | Anomaly Score | Peer Percentile | Exposure ($k) | Severity |
|---|---|---|---|---|---|---|
| MD-018 | Cardiology | Duplicate billing (paired CPT 93458 + 93306) | 88 | P98 | $285.0 | high |
| MD-042 | Orthopedics | Modifier 25 overutilization (37% of E/M visits) | 76 | P92 | $185.0 | high |
| MD-007 | Dermatology | Mohs CPT 17311 billed without pathology support | 92 | P99 | $425.0 | critical |
| MD-034 | Psychiatry | 90837 (60-min) at 78% of visits vs 35% peer median | 82 | P95 | $220.0 | high |
| MD-056 | Pain Management | Billing 64483 epidural injections > weekly on same patient | 95 | P99 | $380.0 | critical |
| MD-021 | GI | Colonoscopy screening CPT 45378 + diagnostic 45380 same day | 68 | P85 | $145.0 | medium |
| MD-089 | Urology | CPT 55700 biopsy 18+ cores per session (limit 12) | 72 | P90 | $95.0 | medium |
| MD-102 | Home Health | LUPA (low-utilization) mix abnormally high (22%) | 58 | P78 | $68.0 | medium |
| MD-119 | PT | Billing units > 8/day per patient (CMS MUE) | 62 | P82 | $45.0 | medium |
| MD-134 | Family Med | E/M 99214 at 72% of visits vs 48% peer | 68 | P88 | $115.0 | medium |
Upcoding Risk — Platform vs Peer
| CPT | Description | Platform % | Peer % | Delta | Volume | Clawback ($M) |
|---|---|---|---|---|---|---|
| 99214 (Est. Office Visit L4) | Moderate complexity | 62.0% | 48.0% | +14.0pp | 185,000 | $2.85 |
| 99215 (Est. Office Visit L5) | High complexity | 18.0% | 9.0% | +9.0pp | 62,000 | $1.45 |
| 99205 (New Office Visit L5) | High complexity - new pt | 22.0% | 12.0% | +10.0pp | 28,000 | $0.85 |
| 90837 (Psychotherapy 60-min) | vs 90834 (45-min) | 72.0% | 38.0% | +34.0pp | 85,000 | $3.25 |
| 45385 (Colonoscopy w/ biopsy) | vs 45378 (screening) | 45.0% | 32.0% | +13.0pp | 12,500 | $0.75 |
| DRG 470 (Joint Rep w/o MCC) | vs 469 (with MCC) | 85.0% | 72.0% | +13.0pp | 1,850 | $0.95 |
| 97140 (Manual Therapy) | vs 97110 (Therex) | 58.0% | 42.0% | +16.0pp | 42,000 | $0.45 |
| J3301 (Triamcinolone) | dose upcoding | 38.0% | 25.0% | +13.0pp | 28,000 | $0.35 |
Referral Pattern Analysis — Stark / Anti-Kickback
| Referring Provider | Referred To | Referrals LTM | Ownership Overlap | Stark Exception | AKS Risk Score |
|---|---|---|---|---|---|
| Dr. Chen (PCP) | Platform Imaging Center A | 382 | YES | in-office ancillary | 72 |
| Dr. Rodriguez (Ortho) | Platform ASC B | 625 | YES | group practice | 58 |
| Dr. Patel (Cardiology) | Platform Cath Lab | 485 | YES | physician-owned entity | 82 |
| Dr. Kim (GI) | Platform Endoscopy Suite | 425 | YES | group practice | 48 |
| Dr. Thompson (PCP) | Non-Platform Imaging X | 18 | NO | n/a | 12 |
| Dr. Johnson (Derm) | Platform Dermpath Lab | 485 | YES | in-office ancillary | 65 |
| Dr. Lee (Oncology) | Platform Infusion Suite | 385 | YES | in-office ancillary | 58 |
| Dr. Garcia (Cardio) | Platform Sleep Lab | 245 | NO | n/a | 82 |
Claim Fingerprint Patterns
| Pattern | Description | Claims Flagged | Dollar Impact ($M) | Payback Likelihood | Remediation |
|---|---|---|---|---|---|
| Ghost Patient Pattern | Same patient billed across 3+ locations same day | 142 | $0.95 | 85% | Immediate provider audit + claim reversal |
| Copy-Paste Documentation | Note text >85% identical across 5+ encounters | 285 | $1.85 | 72% | Physician documentation training |
| Modifier Stacking | Stacked modifiers (25, 59, 51) on same claim | 185 | $0.62 | 68% | Claim edit rule update |
| Unbundling | Global code billed separately from component services | 95 | $0.78 | 82% | Coding compliance review |
| Medical Necessity Gaps | Diagnosis code doesn't support procedure | 225 | $1.25 | 55% | Enhanced prior-auth workflow |
| Repeat Service Abuse | Same diagnostic procedure in shorter than clinical window | 68 | $0.45 | 78% | Utilization review protocols |
| Timely Filing Pattern | Delayed claims batched to specific month-end | 42 | $0.15 | 25% | Cycle improvements |
Geographic Cluster Anomalies
| ZIP | Provider Count | Volume vs Pop (norm) | Cluster Severity | Service Line |
|---|---|---|---|---|
| 85032 (Phoenix) | 12 | 3.85x | severe | Urology |
| 33156 (Miami) | 18 | 4.25x | severe | Home Health |
| 77379 (Houston) | 8 | 2.85x | moderate | Pain Management |
| 32837 (Orlando) | 15 | 3.15x | moderate | DME |
| 89147 (Las Vegas) | 10 | 2.95x | moderate | Behavioral Health |
| 90210 (Beverly Hills) | 22 | 2.45x | moderate | Dermatology |
Compliance Event History
| Event | Date | Type | Resolution | Financial Impact ($M) |
|---|---|---|---|---|
| OIG Subpoena — Billing Audit | 2024-06-15 | civil inquiry | closed — no action | $0.000 |
| Payer RAC Audit Finding | 2024-09-22 | administrative | repaid + education | $0.385 |
| State Board of Medicine Complaint | 2024-11-08 | licensure | dismissed | $0.000 |
| CMS UPIC Data Request | 2025-01-22 | administrative | ongoing | $0.000 |
| DOJ Declination (qui tam) | 2025-03-15 | civil inquiry | declined to intervene | $0.000 |
FWA Detection Thesis: 29 distinct anomalies surfaced across billing, coding, referral, and geographic pattern-matching.
Aggregate financial exposure $17.5M if all findings sustained.
Highest-concentration risks: upcoding on E/M codes 99214/99215 (85% pattern across network) and modifier stacking in surgical sub-specialties.
Ownership-overlap referral patterns trigger AKS / Stark review for 6 of 8 intra-platform chains.
Immediate remediation: audit top-10 anomaly-score providers, roll out documentation training, and implement real-time claim-edit rules before next submission cycle.
OIG/DOJ engagement on current matters has resulted in no material financial impact — active compliance program demonstrates good-faith effort.