You secured a summer internship with an American company that processes dental insurance claims for insurance companies. The company receives the insurance claims from dental offices, achieves authorization from the correct insurance company, and sends payment cheques. You do not deal with dental customers directly, instead, you work with insurance companies on one side and dental offices on the other. After two months with the company, you think several 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. You receive the following three files: 1. ch08_dentists.csv 2. ch08_claims.csv 3. ch08_patients.csv
Question 1: Some dental offices may not employ real dentists and may be front companies that are sending claims out for work not performed. A real dental office should have a real office address with dental chairs, reception areas, and so on. Are any dental offices instead using post office boxes in their payment addresses?
Question 2: Real dentists should be sending claims to many different insurance companies. Because 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. Search the claims file for sequential numbers from any given dental office. Are any sending you sequential claims?
Question 3: A human adult has 32 permanent teeth. Your company requires that each claim list the patient seen (identified by “patient id”), the tooth worked on, and the type of work done. Because of the natural limitation on the amount of cavities that could be filled on any one person, it is rare that a person would have more than a few cavities in three months of your audit (it is possible for a tooth to have more than one cavity). Using this field, calculate the total number of cavities submitted for each patient. Do any patients seem to be visiting the dentists too often?
Question 4: Patients normally need to live close to their dentists because receiving service requires a visit to the office. A good fraud search is to calculate the distance from each customer’s address to his or her dentist’s office using a geographic information system like Google Maps or MapQuest. For this question, simply determine if any patients live in different states than their dentists. Do any patients seem to have a long drive to their dentists’ offices? Include an explanation of the steps you undertook to reach your findings.
Tasks: 1. Provide a written response for each of the four questions. In each of your responses, include an explanation of the steps you undertook to reach your findings (16 marks).
2. Provide a summary that specifies the dentist/s you believe are submitting fraudulent claims. In preparing your summary, clearly specify the reasons to support your conclusions (4 marks). The submission should not exceed 2,000 words.