Claims scene investigation: They're watching you

Whether you realize it or not, health plans are tracking your every step, looking for signs you're costing them too much. But there are ways you can watch the plans, too.

By Robert Kazel, AMNews staff. Oct. 27, 2003.

The computer system at Aetna's special investigations unit in Middletown, Conn., watches what physicians do and how they do it. The software, dubbed FAMS for Fraud and Abuse Management System, strives to separate the good doctors from the suspected bad apples, and it keeps an ongoing list of the latter.

The list constitutes a sort of "report card," says Mike Stergio, Aetna's head of special investigations. At one end are the "pretty straight shooters" -- those doctors deemed to be unlikely committers of misdeeds because their treatment patterns jibe with those of doctors in the same vicinity and specialty. At the other end are those Stergio calls the "most egregious billers" whose style doesn't appear to match that of other doctors at all.

A doctor who sends every patient for an x-ray, for instance, might well arouse FAMS's interest -- and eventually Stergio's as well -- if the majority of doctors of the same specialty and in the same community order an average of three x-rays a week.

"Honest doctors will probably never hear from a special investigations unit -- never," says Stergio, who solved homicides and bank robberies as a lieutenant in the major crimes squad of the Connecticut State Police before joining Aetna. "I'd go as far to say 97% of the doctors never will. [But] we have a zero-tolerance approach. We can't let it go, regardless of the amount of loss."

Business is bustling in Stergio's office. Reports of fraud are up, as is the number of workers pursuing them. When Stergio joined the investigative staff in 1995, there were 19 people on the team. Now he directs a staff of 107.