Results & Impact

A staffing company enrolls 12 "nurses" in state Medicaid with licenses obtained from diploma mills. Cross-referencing with state licensing board databases reveals no valid credentials. 47 false claims submitted over 6 months = $340K in fraud prevented.

A physician with felony conviction continues billing through corporate entity after debarment. Network matching against OIG exclusion lists reveals the relationship. $128K in claims blocked before payment. Regulatory referral submitted to CMS.

Cross-state data correlation identifies beneficiary enrolled in three states simultaneously. Sentinel flags utilization pattern anomalies (same provider visits in different states on same days). $89K in improper payments recovered across two states.

Beneficiary claims unemployed status but IRS W-2 data shows income above threshold. Six-month income review identifies $42K in improper benefits paid. Case referred to state fraud investigator for criminal referral.

Home health provider bills for 8-hour visits every day for 90 days for patient documented to have been hospitalized for 75 of those days. Pattern analysis flags impossibilities. $267K in fraudulent claims denied. Provider agreement terminated.

Therapy provider systematically upcodes simple PT to complex PT, increasing reimbursement by $400+ per claim. 1,200 claims over 12 months. Medical necessity review disputes 89%. $428K recovery identified.

System glitch causes same claim to be paid twice by MCO. Sentinel's payment reconciliation catches the duplicate before discovery by audit. $340K claim recovered within 30 days of payment.

Medical equipment supplier's claims are paid at 120% of contracted fee schedule rate across 18 months. Statistical analysis reveals systematic overpayment. $156K recouped through claims adjustment process.