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Statistical Results

Corporate and Financial Investigations Department

January 1, 2004 to December 31, 2008

Corporate and Financial Investigations
Subject type
Fraud tips received
Cases initiated
Tips under investigation
Professional provider 2,569 321 1,075
Group administrators/Brokers 67 23 21
Hospital 319 11 85
Pharmacist 76 15 17
Subscribers 518 203 238
Associate 200 191 110
Misc. 999 236 325
Pharmacy 1,242 10 654
Total 5,990 1,010 2,525
Referrals for Criminal Prosecution
Federal 142
Philadelphia District Attorney 27
State of PA 54
State of NJ 19
NJ Office of Insurance Fraud-Prosecutors Office 40
NJ Licensing Bureau 2
PA Licensing Bureau 12
Misc. 28
Regional Advantage Services (RAS) 1
Total 325
    Indictments/Criminal Information Filed 85
    Sentenced 65
Financial Results (Fraud, Waste, and Abuse)
Restitution
Court Ordered $8,066,055
Investigations/Support Recoveries $3,320,922
Claim Recoveries
Professional Claims $7,233,326
Facility Claims $149,542,819
Claims Denied (Averted Savings) $5,264,921
Recovered Savings/Checks Stopped $699,316
Recovery Claim Offset $2,069,044
Misc. Restitutions $1,235,289
Pharmacy Audit Recoveries
Durable Medical Equipment $1,797,391
Home Infusion Therapy $3,451,409
Retail $5,793,813
Checks Received $1,885,685
Claim Offset $2,233,455
Totals
Financial Results $192,593,445
    Group Charge Audits $214,293,817