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AmeriHealth New Jersey 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 160 12 56
Group administrators / Brokers 10 6 4
Hospital 16 1 8
Pharmacist 4 0 2
Pharmacy 116 1 17
Subscribers 56 12 34
Associate 12 13 11
Misc. 63 22 27
Total 437 67 159
Referrals for Criminal/Civil Prosecution
NJ Attorney General’s office 15
NJ Office of Insurance Fraud — Prosecutor’s Office 40
Prosecutor’s Office 7
NJ Licensing Bureau 2
Misc. 1
Total 65
    Indictments/Criminal Information Filed 5
    Sentenced 4
Financial Results (Fraud, Waste, and Abuse)
Restitution
Court Ordered $200,579
Investigations/Support Recoveries $32,703
Claim Recoveries
Professional Claims $320,927
Facility Claims $3,176,402
Claims Denied (Averted Savings) $720,688
Recovered Savings/Checks Stopped $33,792
Recovery Claim Offset $33,777
Misc. Restitutions $45,059
Pharmacy Audit Recoveries
Durable Medical Equipment $12,971
Home Infusion Therapy $58,023
Retail Desk Audit $46,480
Totals
Financial Results $4,681,402
    Group Charge Audits $2,580,507