Nicholas J. Messuri, Esq., Vice President and Deputy General Counsel for Fraud Prevention & Recovery at DentaQuest, a national dental insurer with corporate offices in Boston, Massachusetts, was elected Chair of the NHCAA Board of Directors for 2016.
Nick has already served NHCAA for several years and has made tremendous contributions to the Association with his innovative thinking and depth of knowledge and experiences, so naturally, I wanted to learn more. I was able to spend time with him to discuss the coming year and here’s what he had to say:
Q1. Nick, congratulations on your election and welcome! You’ve mainly worked on the medical side of the health care anti-fraud industry, with your transition to DentaQuest, can you tell us a little bit about the unique challenges you’ve found in the dental arena?
Thank you for the question Katie. My new position as Vice President and Deputy General Counsel for Fraud Prevention & Recovery at DentaQuest has been both challenging and rewarding. Most of the challenges relate to the volume of work involved with overseeing a national anti-FWA program. This is the first opportunity for me to be involved with a program that has business in 30 states and over 27 million members.
It has been rewarding for two reasons: first, I have inherited a strong and dedicated staff with a commitment to professional auditing; and second, I am returning to the protection of Medicaid dollars and members, similar to the responsibilities I had as a 10 year Chief of the Massachusetts Attorney General’s Medicaid Fraud Division. Unlike most medical companies my investigators focused on while at Tufts Health Plan for the previous 9 years, the dental practices we typically encounter at DentaQuest are smaller and singular. There is a greater financial impact at stake and every case has the potential to be fought to the last dollar. Similar to medical investigations, my team has to be accurate and precise and, the fraud and abuse schemes are similar to the ones observed in the medical arena.
Q2. The last few years have seen great changes in the health care anti-fraud industry, particularly the shift toward greater use of analytics and the expansion of health care. What do you see as the most challenging issues this year?
Well, I believe the two you mentioned, data analytics and expansion of health care, are in the top five for us investigators. The analytic industry, and to what extent our companies utilize data analytics, impacts not only the overall success of fraud units, but the challenges of private plans to determine the right balance between prepayment prevention strategies and back end assessments of conduct and intent.
For health and dental plans, finding this balance is paramount because an effective anti-FWA program deploys both cost saving measures. Health care expansion has opened up new avenues and opportunities to commit fraud that are still being measured and playing catch-up is an uncomfortable place for fraud units.
Q3. With that answer in mind, do you have any goals for the Association to meet these challenges?
I do. NHCAA has been adept at bringing the best anti-FWA practices to the forefront. Our public-private partnership is the best in any industry. Our trainers are unselfish and I have complete confidence in our Annual Training Committee to find the best of our membership that have the newest ideas for tackling these subjects. We are asking all of our partners to take collaboration to a higher level.
I also have challenged our Board to capitalize on the expertise of the NHCAA staff and the expert leadership of Chief Executive Officer Lou Saccoccio. For example, we are currently acting on ideas to partner at a greater level with our Medicaid fraud enforcers, assisting the Health Care Fraud Prevention Partnership (HFPP) to move forward with their mission to share data analytics, and we continue to strengthen our relationships with our law enforcement and global partners.
Q4. It looks like we have a busy year ahead of us! With the challenges and goals we just discussed in mind, how do you think members can best capitalize on their NHCAA member benefits?
I would encourage everyone who is eligible to utilize CONNECT to communicate and build their network. It’s an excellent forum for asking questions about investigative techniques, intricacies of a scheme or specialty area, gain insights on coding, and discuss management issues.
In addition, members need to be sure they utilize their many benefits by leveraging information from SIRIS, tapping into information provided by Government Affairs, using the Anti-Fraud Management Survey, and keeping apprised of current fraud trends by attending any of the training programs throughout the year. All of these avenues also assist in supporting our private-public partnership to work with law enforcement as partners in the fight against fraud in the health care system.
Lastly, one of the best benefits of being a part of NHCAA is the networking. CONNECT, SIRIS, and in person training can put members in touch with people from across the country who see different schemes and use different investigative techniques. For those who have worked with unique schemes or specialty areas, I’d strongly recommend becoming part of our faculty to share that knowledge and broaden your own skill set.
Q5. On a lighter note, can you tell us about one of your favorite investigations and what the case entailed?
Oh gosh, I have twenty years of stories, but maybe the most relevant, and a favorite, occurred during my first year in health care fraud enforcement. My team identified a psychiatrist that appeared to be abusing Medicaid time-based procedure codes to the degree that there was not enough time in the work day to complete his work as billed.
Through surveillance we had a sense of his average day, but during our on-site interview he was defiant and squarely blamed the incompetence of his young billing staff. The interviews of his staff confirmed their inexperience, but the investigation established that the provider had very high credit card expenditures, lots of travel, and a high standard living to support. The Medicaid investigative team began its own private/public mission to learn the extent of the provider’s billings to the private plans in Massachusetts.
This step produced evidence that often would have produced a guilty plea as the provider was also billing private plans several hours each day on top of his Medicaid billings. These hours brought the total number of days where more than 18 hours were billed to 150. However, once formally accused, the provider retained a high powered law firm and a talented defense attorney that argued the provider’s ignorance of the billing.
During trial defense counsel was able to prove that the provider was a very busy and successful psychiatrist with both a hospital and office based practice, but his young staffers gave enough information on cross examination for us to ask the judge to give a willful blindness/deliberate ignorance jury instruction*.
It was risky because the principle had never been used in the Massachusetts state courts therefore creating an issue for an appeal. In my first health care fraud closing argument, the risk paid off as the judge did issue the instruction, the jury found him guilty, and the Appeals courts affirmed that this new jury instruction was applicable when providers blame others. We made new law that has helped prosecutors fend off a common defense strategy in the white collar crime arena.
*An instruction given by a judge to the jury that indicates they may find the defendant acted knowingly if the jury members believe there was a high probability that the defendant knew there may be issues (i.e., with the billing), but deliberately avoided learning the truth.
NHCAA (Katie): Nick that is an amazing story! Thank you for sharing it, and your other thoughts on the Association and health care anti-fraud industry, with us today. Congratulations on your election and here at the Association we are looking forward to your leadership for 2016 and beyond.