identified . This data analysis is key in the identification of repetitive questionable patterns .
The data analysis consists of claims data mining and rules-based analysis to identify possible instances of fraud and abuse .
The computer based analysis includes provider , facility , pharmacy , and member claims data . Patterns of over-utilization , false claims , or other unusual billing practices are addressed .
b ) Fraud / Suspicious Claim Sources
All providers , staff and entities have a critical role to play in the lawful and ethical conduct of Hometown Health ’ s business . The goal is to have all providers , staff and entities take the time to understand the principles behind the laws and regulations that underlie the company ’ s policies in order to be aware of conduct that is lawful and appropriate .
All providers , staff and entities are required to comply with all federal and state laws , statutes and regulations regarding FWA .
In addition to detection software , Hometown Health employs several other lead activities , such as :
• Complaint tracking
• Leads from other internal departments
• Fraud and Abuse Hotline
• Tips from members , the general public or employees
• Media reports
• Office of Inspector General Alerts
c ) Investigation
The Compliance Manager will coordinate the need to conduct an investigation and to take corrective action . The disclosure of certain information may be required . Investigation procedures may include :
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