Federal Reports

This resource guide explains our approach to using claims data to identify incidents of potential abuse or neglect of vulnerable populations. The guide synthesized the methodologies that OIG developed in our extensive work on identifying unreported critical incidents, particularly those involving potential abuse or neglect. These methodologies were used in work examining a variety of care settings, including nursing facilities and group homes. The guide includes a flow chart showing key decision points in the process and the detailed lessons that the OIG has learned using this approach. We encourage our public and private sector partners to use this guide to develop a process tailored to their specific circumstances and apply it to any vulnerable population they deem appropriate. The source of the data could include Medicaid Management Information Systems claims data, private payor insurance claims data, or similar data sets. Analyzing the data to target which medical records should be reviewed can help identify individual incidents of unreported abuse or neglect, patterns and trends of abuse or neglect involving specific providers, beneficiaries, or patients who may require immediate intervention to protect their health, safety and rights. The guide also provides technical information, such as examples of medical diagnosis codes, to support our public and private sector partners with analyzing their own claims data to help combat abuse and neglect.

Three Florida residents pleaded guilty in June and July 2019 in U.S. District Court, Southern District of Florida, to criminal charges related to healthcare fraud as the result of an Amtrak OIG-supported investigation. Eric Snyder, owner of a substance abuse treatment facility and a sober home residence located in Delray Beach, pleaded guilty to conspiracy to commit healthcare fraud on July 23, 2019. Christopher Fuller and Joseph Lubowitz, patient brokers, who recruited patients for Snyder’s substance abuse treatment center, pleaded guilty to the same charge on June 26, 2019. Snyder owned Real Life Recovery Delray, LLC, a purported substance abuse treatment center that offered clinical treatment services for alcohol and drug addiction. Additionally, Snyder owned a sober home, Halfway There, a residence purported to provide a drug-free living environment for those undergoing substance abuse treatment. As part of a scheme to fraudulently bill patients’ insurance, including Amtrak’s insurance plan, Real Life Recovery required clients to undergo excessive and medically unnecessary tests, fraudulently billing insurance providers for the tests and other treatment that patients did not receive. In exchange for submission to such tests, kickbacks and bribes in the form of free or reduced rent, payment for travel, and other benefits were provided to insured individuals who agreed to reside at Snyder’s sober home and attend treatment at Real Life Recovery. According to court documents, in addition to recruiting patients for Snyder’s business, Fuller and Lubowitz both knew of the kickbacks and bribes, and were aware of or indifferent to the fact that insurance claims based on medically unnecessary drug testing and treatment, as well as therapy sessions that were never provided, were submitted to Real Life Recovery’s patients’ insurance plans.