Payment Integrity Investigations

Dr Margaret Faux was engaged to provide an expert opinion concerning allegations of Medicare fraud in criminal proceedings. This project involved analysing over 7,500 lines of Medicare claims and associated clinical records to provide an opinion concerning whether the available evidence could support a criminal fraud conviction.

Dr Margaret Faux was engaged to provide an expert opinion regarding Medicare billing compliance by a medical specialist. This project involved analysing the full sample of claims seized by the PSR and reporting her opinion on whether the evidence supported compliant Medicare billing by the practitioner.

Dr Margaret Faux was engaged to provide an expert opinion regarding Medicare billing compliance by a medical specialist billing to Medicare at a public hospital. This engagement included Dr Faux appearing as an expert witness before a state inquiry.

Our client was a state regulator of a workers compensation scheme who was concerned about the incidence of fraud and abuse it believed was occurring in certain areas.

The project involved analysing 32,000 lines of medical billing claims including anaesthesia, surgery, surgical assisting, diagnostic imaging, procedures for pain including spinal cord stimulators, miscellaneous diagnostic and therapeutic investigations and procedures, and pathology.

We conservatively estimated that 33% of claims were incorrect, totalling almost $10 million.

Our client engaged us to analyse approximately 26,500 lines of Medicare claims valued at over $35 million which spanned a one-year period. These claims were billed by over 200 GPs.

This project was undertaken in the context of due diligence related to a potential acquisition.

The client did not proceed to make this acquisition.

Synapse Medical Services is delighted to announce that we are leading a national project to develop the non-admitted patient classification for the #Kingdom of Saudi Arabia across 9 clinical streams.

Project Team: Prof Kathy Eagar, Dr Margaret Faux, Annette Panzera, Heather Grain and Hala from our KSA partner, Anova Health.

The project is an initiative of the #National Casemix Centre of Excellence, aligned with #vision2030 of the Kingdom. 

The project team, led by Dr Margaret Faux, and with our KSA partner, Anova Health, and Australian company, Clarisoft , will design, test and pilot V1 of the classification, and make recommendations for V2 and beyond.

It is an honour to have been selected, and the team have been busy getting the project moving over the last few months. This project is a bit like building #Medicare from the ground up, and implementing it. Truly exciting!

Embassy Australia – Project Team

We are thrilled to be working on this groundbreaking project. Thank you to Australian Ambassador to Saudi Arabia H.E. Mark Donovan for the warm welcome in #Riyadh.

Our national non-admitted patient classification project team in the #Kingdom of Saudi Arabia has been involved in two weeks of intensive workshops with stakeholders across the spectrum of healthcare delivery. 10 amazing days of wonderful clinician engagement, future planning and project delivery. Led by Dr Margaret Faux, Annette Panzera, Heather Grain, Michael Richter, Manal Al Khalifah, Hefin Jones, Ehab Alatassi and the wonderful Kathy Eagar.

Left: One of the workshops – Dialysis. Superb clinician engagement.
Right: Ehab Alatassi, Executive Director of National Casemix Center of Excellence, KSA and Professor Kathy Eagar.

Another international consultancy project that Synapse has in progress currently is a one-time mapping of internal codes for a market leading government hospital in the Middle East.

The hospital had been using self-made internal codes that had developed over time. These codes for procedures and diagnosis meant very little outside of the facility.

The country in question was making the transition to ICD-10 AM and therefore this presented a significant problem with regards to data collection and reimbursement processes which are transitioning to DRGs.

Synapse is mapping 12,000 codes using a hybrid of Australian and U.S codes as per the clients’ requirements, including adding RVUs. This will facilitate a new system of data processing to be implemented across the facility.

This project involves significant resource, deep knowledge of international coding processes and internal training to explain why the changes were required.

This facility will soon be well placed for framework changes that are becoming mandatory at a national level.

Our consulting services extend internationally through our global network. One wonderful initiative we are involved in is to assist a state in India with regards to the gathering of critical health data, prior to the implementation of an electronic medical record.

This large scale consultancy project will allow us to offer market leading technology, resource and knowledge to develop baseline metrics on the incidence of disease and current health service delivery patterns across the state. This wasn’t previously possible due to limitations in technology and data storage.

Our proprietary in-house software is able to convert data into numerous clinical codes including ICD-10 and Snomed-CT to enable epidemiological analysis.

This project will be offered in three phases due to the volume, and will commence with Synapse coding 100,000 clinical episodes over a three-month period.

The project will also involve an educational element so that local healthcare professionals can be trained to continue the development of healthcare data management and storage.

Upskilling of local people and employment opportunities will be created through the training that Synapse can provide.

This is another one-time consultancy project that we hope will turn into a long-term relationship.