False Claims Healthcare Provider

False Claims Prevention: VA Seeks Fraud Detection Software For Non-VA Healthcare Providers

VA just put out a tender notice seeking information on software to support fraud, waste, and abuse detection to prevent false claims by non-VA healthcare providers.

The announcement came one week after the agency looked foolish explaining its numerous software problems administering disability and GI Bill benefits. Agency leadership was largely unable to explain away numerous software deficiencies.

Perhaps the software inquiry is a first step to detect where the breakdown occurred. But, more likely, the agency is seeking some AI software to data mine. The performance work statement indicates the software is to combat false claims from non-VA healthcare providers.

VA shows the following:

This COTS configurable software will serve with the VA-FSC’s healthcare claims adjudication enterprise solution, eCAMS HCE. The Contractor, acting independently and not as an agent of the government, shall furnish all the necessary services, qualified personnel, material, equipment, supplies, and facilities except as otherwise specified herein, and otherwise do all things necessary for or incident to performance of requirements described in this work statement, also referred to as the Contractor’s Performance Work Statement (PWS). 

The intent of the software is to eliminate false claims. The False Claims Act (31 U.S.C. §3729), allows American citizens, whether affiliated with the government or not, to file actions against federal contractors claiming fraud against the government.

The False Claims Act was passed by Congress to prevent the United States Government from paying federal funds for fraudulent claims involving goods and services. For VA, this would include submitting false information in order to receive a higher reimbursement. Examples of this include upcoding (i.e., coding a higher DRG than the documentation support), lab unbundling (i.e., charging separately for procedures usually charged as one procedure), billing for services not actually rendered and duplicative billing.

False Claims Prevention

From Performance Work Statement

Here are some specifics from the publication that may reveal possible records to FOIA for research in the future.

The inquiry publication shows VA is seeking detection software using “predictive analytics based” software that will using the following tools:

  • Predictive Analysis
  • Link Analysis
  • Surveillance and utilization review system

Importantly, the software must be capable of identifying and learning from fraudulent patterns and scenarios to reduce false positives and adapt predictive algorithms against emerging schemes.

The system shall track the original source of alerts as well as the ultimate resolution of alerts and pass this information back to VA-FSC. The data collected shall provide for results reporting such as:

  • False Positive rates
  • Return on Investment and Cost Avoidance
  • Alerts and scoring results
  • Number of revocations, payment suspensions, claims denials, claims rejections or other actions.

[documentcloud url=”https://www.documentcloud.org/documents/5485234-VA-Fraud-Waste-Abuse-Detection-Software.html” responsive=true]

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  1. A choice card in Alabama is useless. A choice card in Oregon is overused, and the Dr’s seem angry. Still, my problem is I’m not getting what I need. I’ve been walking around with a hernia, as a result of surgery the VA is responsible for. They just won’t allow me to see the proper Dr. I just bought a supplement for Medicare, plan F. Now it’s finding a Dr., who takes Medicare. I’m quite certain that nearly every Veteran here, has a valid reason to sue the VA. I’m going on 20 years on an appeal. I have 30% on claim. Been operated on twice and hospitalized three times, and now it’s being remanded, whatever that means. God Bless the Veterans..

    1. See my response to Bryce above. You may have a tort claim in addition. If enough of us get together we can probably get a pro bono attorney or at least one that will take it for the costs he can recover from the VA.

  2. I know some of you have been in this game a lot longer than I and have seen this dog and pony show before, but I’m going to be optimistic and hope this program is about good people trying to right the wrong, trying to work the problem. I know it can easily end up just like all the other false hopes we have had about repairing the broken system, to no avail. However what’s the alternative? This is a massive organization and it’s problems mimic it’s size. Not an easy fix especially with all those self-serving, dastardly varmints feeding off the teat of the US VA.

    And speaking of these egotists mentioned above, I have a medical appointment coming up and become uneasy because I have to go to the VA. It’s not due to anything serious just a annual checkup, no biggy. But then this got me to wondering, why do I feel so edgy about going? Annnnd I realized it is because many times I have been treated condescendingly by people who are less educated than myself and in many cases not even a veteran. Then the epiphany, when I go to the VAHCS appointment I feel as if I am being socially shamed for utilizing my EARNED VAD benefits.

    Now here’s the clincher, I feel that when the VA awarded me my benefits, I proved my claim and won what would be called out in the private sector a “personal injury lawsuit”. Now I have never came across anyone who dishonors an individual who had won this type of lawsuit; as a matter of fact they are glorified and seen as courageous for standing up for themselves and persevering. Yet when a veteran goes through the same process, the only difference is the way the claim has to be processed, we are ridiculed and shamed! Annnd on top of that, by people who never had the integrity and fortitude to serve this great country!

    Now that just doesn’t sit well with me, I’m just saying.

    God speed

  3. The VA has opened itself to the Fraud that was endemic in Medicare and Medicaid with the Choice Program and CBOC Contracts. This administration has scaled back recovery and criminal prosecution of Fraud by more than 80% from the days the Obama Administration was reeling back in over $3 Billion per month. It was stopped almost completely until the last couple of months. And nothing has appeared in the DOJ News Letter, “[email protected]” : which I receive. Few big settlements above single digit millions.

    1. May be a little early to see the Choice and CBOC contractors in the letter. ER operations, as with Medicare and Medicaid plus Pharmacy and medical appliances should have shown up long ago but the fraudsters have been getting away with it not to mention subscriptions showing up on vets pharmaceutical records that the vet never received or needed.

  4. The Dr. I was seeing on Choice lowered his rates so Vets could see him after one of his staff’s spouse, (A Vet), told him what a terrible time he was having with VA MH, to the SS rate. He also said it took Choice 6 months to start paying them. Their staff in financial dept. said they can’t even get anybody to ever answer or return their phone calls in Non- VA care and Choice when they called. I thought the people running Choice were being looked into for fraud, not the other way around. Just sounds like a big VA deflector shield going up to me….

  5. Be aware there are very specific actions that must be followed if launching a False Claims case. Get an attorney familiar with False Claims law, and don’t hold your breath.

  6. That’s also part of why I straight switched to private using my Tricare. The VA is a clown ? show right now ??‍♀️

  7. See Ben I told you the Choice Act Drs were taking advantage of vets & thus by extension the VA. Thank goodness they’re trying to get it under control. Those Choice Act Drs were even trying to force vets into medical procedures they didn’t actually need just so they could charge beacoup $ to the VA. I’m for private drs but this $h!t was getting ridiculous.

  8. A little off subject, only I believe it needs discussed.
    Recently, I was in the hospital. The hospital says, “Before they can submit a claim. They need an ‘authorization number’!
    The VA says, “The hospital needs to submit the claim first!”

    Thank God I’ve got “Medicare Part 1” (hospitalization)! I might have to pay some, but I think I can manage it. At least my credit score won’t suffer.
    The wife wants to sue the VA. I agree!

  9. To whom who read this can you please tell me is President Donald Trump Hotline be trusted?

    1. I’ve sent comments, don’t know if they’ve gotten to the President. It usually takes 10-20 min.’s to get a volunteer operator, who asks for a brief comment. I don’t see how he could answer all the input. Try to send
      my support… As far as trust, I’m sure somebody hears it, and categorizes it for him… I would recommend using it.

    2. 1 year ago, I called the hotline to complain about veterans choice care bills not being paid. It took several months for a case worker to contact me. Then every 2 weeks that same case worker called to tell me the same thing, ‘she was not getting a response from (health net) the bill payer for choice. That went on for several months, complained again, new case worker, I got the same response, every 2 weeks, till finally I told her to stop calling with no news.
      The moral of the story, I drive 2 hrs for care, instead of a few minutes, so the hot line was worthless to me.

      1. I almost forgot, I talked with a disabled Navy veteran,,, he told me that thousands, tens of thousands of disabled veterans and disgruntled veterans were blowing up the hotline,,, that was a year ago!

      2. Bryce, I’m filing a complaint to the U S Court of Federal Claims this week in Pro Se. I’ll pay the fee and would be pleased if anyone who can get a copy of their outstanding bill and treatment records from their Choice Provider would join me. For information contact me at “[email protected]” (email address without the quotation marks). Remove any personal ID markers such as SS# or VA Claim # from anything you send me or mail it to the address I’ll send you. I’ll scan it and redact it as required for filing. If you join with me now you won’t have a filing fee. If you qualify for a Declaration of Financial Hardship we may be able to get an attorney to take a class action on the behalf of the many veterans and Choice Providers that have been adversely affected. If you and others join it will take more than a week to file the complaint. If I receive an email from you I’ll send you a copy of what I filed at the Court of Appeals for Federal Claims which was returned to me with instruction to file at the lower court where discover can be obtained and Health Net financial records can be obtained in discovery. We can go after them for 20% of what the Government collects in retribution on our complaint or force the House to appropriate the funds per the “entitlement” contract.

        The VA approved this care and sent a brother to pay the bill. The brother absconded with the funds. It is the same as if I sent my brother to pay my mortgage and he used the funds for something else. I’m still responsible for my mortgage payment and my brother is responsible to return the funds he embezzled. I can file a complaint against him but I must cover my mortgage because the bank has its complaint against me.

        This is one of the “private contractor” embezzling funds that the Obama Administration took to task for more than $3 billion a month. That has dwindled to less than $5 Billion since Trump’s AG took office. Tax payer dollars are funding scammers. The scammers that engineered the Choice Contracts through the Phoenix/Cheyenne VA Medical Center crisis which happened under the Obama Watch and appropriate accounting controls were not put in the contracts by the GAO.

  10. Yep…chocolate covered shit with edible gold leaf foil with unicorn fairy dust sprinkles=STILL THE VA TURD.

    How about an asshole-detecting algorithm app for Vets so we can firstly scan the hack with the app’s software and it will stop all nonsense before it even begins by returning an exact replica red buzzer sound from board game of ‘Operation’ and promptly tells the VA hack detected to go back to the muddaland hut and DO NOT collect $200.??!! <—THAT software would save Veteran lives!!!

    1. One of my weasels just got out of the rack to squirt out a turd and it kinda sounded like and looked like margaritas devilin eggs or whatever that fat, fraudulent narcissist cunts name is.

  11. VA stop your hiding by PR’ing smokevand mirror tactics. Every Veteran on.this stream wouldn’t argue against the VA having to be audited, and regularly being monitored.

    Come on Set the Standard by putting up yourself like you put others up. My goodness, when are you VA going to be transparent.

    I have a gut feeling, that theres 100’s of $millions$ or more that is unaccounted for. Come on VA, put up or shut up.

    1. Pussy cowards won’t. Sissy boys always have to hide behind smoke and mirrors so you don’t see the tiny inept man behind the big screen pulling the levers.

      Pieces of dog shit every last one of them. Anyone who simps for them or shills for them is just as fresh and stinky as a freshly squirted cat or ferret turd. New world order garbage fucks.

  12. We all know that they are just trying to make themselves look good on the outside.

    You can cover fresh dog shit in batter and sugar and fry it but at the core, beyond the sugary golden brown exterior is a center nougat of dog shit.

    They are 100% guilty of fraud, waste and abuse which is also rampant in the military and DOD. I should know, I worked in headquarters battery and watched our Filipino supply sergeant get burned for waste and abuse by ordering expensive gear, only giving it out to his click and denying Joes mission essential gear. This was early in an Iraq deployment 2008.

    Same as commanders trying to burn up ammo and giving away unused supplies so they can justify getting more money in the next budget. Sure Joes like to go out and shoot up thousands upon thousands of rounds but to be honest it’s a total waste if your on the firing line shooting at nothing for the sake of burning up ammo.

    Difference here is that my money, the money I earned the day I got injured in the line of duty and the money that many other service veterans who saw war is going in undeserving, lazy affirmative action low iq lying pieces of shits pocket therefore reducing the quality of life the nation’s hero’s earned earned all because a small segment of the black population is too lazy to actually work.

    But let’s not forget the spoiled, greedy narcissistic suburban trash in middle and upper management who have more brains and therefore figure out how to steal more money or make it look like they are working harder.

    I’m no old man (30, 31 in January) but the army didn’t train no fool for the front line.

    They trained a sharp warrior.

    1. So the (small) low iq, affirmative action Lazy Blacks is messing up the 20+million vets quality of life??? I thought the VA and the Welfare/Trailer Park Trash care budgets were Different? The more you go on a Ramble the more you sound like the Lower IQ subject dude the two don’t compare TO a person of wisdom with COMMON FKN SENSE…

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