| """ |
| Synthetic government fraud documents for all 3 tasks. |
| All data is entirely fictional. Generated deterministically so graders are reproducible. |
| """ |
|
|
| from __future__ import annotations |
| from typing import Any, Dict |
|
|
|
|
| |
| |
| |
|
|
| TASK1_DOCUMENTS: Dict[str, Dict[str, Any]] = { |
| "CLAIM-001": { |
| "doc_type": "medicare_claim", |
| "title": "Medicare Claim #MC-2024-001", |
| "preview": "Patient P4421, Procedure 99213, Date 2024-03-15, $185.00", |
| "content": { |
| "claim_id": "MC-2024-001", |
| "patient_id": "P4421", |
| "patient_name": "Robert Haines", |
| "procedure_code": "99213", |
| "procedure_desc": "Office visit – established patient, moderate complexity", |
| "service_date": "2024-03-15", |
| "billed_amount": 185.00, |
| "provider_id": "PRV-8821", |
| "provider_name": "MedCorp Associates LLC", |
| "npi": "1234567890", |
| "diagnosis_code": "Z00.00", |
| "place_of_service": "11 - Office", |
| "submitted_date": "2024-03-22", |
| }, |
| }, |
| "CLAIM-002": { |
| "doc_type": "medicare_claim", |
| "title": "Medicare Claim #MC-2024-002", |
| "preview": "Patient P4421, Procedure 99213, Date 2024-03-15, $185.00", |
| "content": { |
| "claim_id": "MC-2024-002", |
| "patient_id": "P4421", |
| "patient_name": "Robert Haines", |
| "procedure_code": "99213", |
| "procedure_desc": "Office visit – established patient, moderate complexity", |
| "service_date": "2024-03-15", |
| "billed_amount": 185.00, |
| "provider_id": "PRV-8821", |
| "provider_name": "MedCorp Associates LLC", |
| "npi": "1234567890", |
| "diagnosis_code": "Z00.00", |
| "place_of_service": "11 - Office", |
| "submitted_date": "2024-03-28", |
| "note": "Resubmission - original claim lost", |
| }, |
| }, |
| "CLAIM-003": { |
| "doc_type": "medicare_claim", |
| "title": "Medicare Claim #MC-2024-003", |
| "preview": "Patient P8832, Procedure 93000, Date 2024-03-20, $320.00", |
| "content": { |
| "claim_id": "MC-2024-003", |
| "patient_id": "P8832", |
| "patient_name": "Linda Forsythe", |
| "procedure_code": "93000", |
| "procedure_desc": "Electrocardiogram, routine ECG with 12 leads", |
| "service_date": "2024-03-20", |
| "billed_amount": 320.00, |
| "provider_id": "PRV-3342", |
| "provider_name": "HeartCare Diagnostics Inc", |
| "npi": "9876543210", |
| "diagnosis_code": "I10", |
| "place_of_service": "22 - Outpatient Hospital", |
| "submitted_date": "2024-03-25", |
| }, |
| }, |
| "CLAIM-004": { |
| "doc_type": "medicare_claim", |
| "title": "Medicare Claim #MC-2024-004", |
| "preview": "Patient P4421, Procedure 99213, Date 2024-03-16, $185.00", |
| "content": { |
| "claim_id": "MC-2024-004", |
| "patient_id": "P4421", |
| "patient_name": "Robert Haines", |
| "procedure_code": "99213", |
| "procedure_desc": "Office visit – established patient, moderate complexity", |
| "service_date": "2024-03-16", |
| "billed_amount": 185.00, |
| "provider_id": "PRV-8821", |
| "provider_name": "MedCorp Associates LLC", |
| "npi": "1234567890", |
| "diagnosis_code": "Z00.00", |
| "place_of_service": "11 - Office", |
| "submitted_date": "2024-03-30", |
| "note": "Date corrected from original submission", |
| }, |
| }, |
| "CLAIM-005": { |
| "doc_type": "medicare_claim", |
| "title": "Medicare Claim #MC-2024-005", |
| "preview": "Patient P2271, Procedure 99214, Date 2024-03-18, $265.00", |
| "content": { |
| "claim_id": "MC-2024-005", |
| "patient_id": "P2271", |
| "patient_name": "Marcus Webb", |
| "procedure_code": "99214", |
| "procedure_desc": "Office visit – established patient, moderate-high complexity", |
| "service_date": "2024-03-18", |
| "billed_amount": 265.00, |
| "provider_id": "PRV-8821", |
| "provider_name": "MedCorp Associates LLC", |
| "npi": "1234567890", |
| "diagnosis_code": "J06.9", |
| "place_of_service": "11 - Office", |
| "submitted_date": "2024-03-24", |
| }, |
| }, |
| "CLAIM-006": { |
| "doc_type": "medicare_claim", |
| "title": "Medicare Claim #MC-2024-006", |
| "preview": "Patient P5519, Procedure 71046, Date 2024-03-22, $410.00", |
| "content": { |
| "claim_id": "MC-2024-006", |
| "patient_id": "P5519", |
| "patient_name": "Dorothy Callahan", |
| "procedure_code": "71046", |
| "procedure_desc": "X-ray, chest, 2 views", |
| "service_date": "2024-03-22", |
| "billed_amount": 410.00, |
| "provider_id": "PRV-7710", |
| "provider_name": "Radiology Partners Group", |
| "npi": "1122334455", |
| "diagnosis_code": "R05.9", |
| "place_of_service": "22 - Outpatient Hospital", |
| "submitted_date": "2024-03-26", |
| }, |
| }, |
| "CLAIM-007": { |
| "doc_type": "medicare_claim", |
| "title": "Medicare Claim #MC-2024-007", |
| "preview": "Patient P9934, Procedure 99213, Date 2024-03-14, $185.00", |
| "content": { |
| "claim_id": "MC-2024-007", |
| "patient_id": "P9934", |
| "patient_name": "Albert Nguyen", |
| "procedure_code": "99213", |
| "procedure_desc": "Office visit – established patient, moderate complexity", |
| "service_date": "2024-03-14", |
| "billed_amount": 185.00, |
| "provider_id": "PRV-8821", |
| "provider_name": "MedCorp Associates LLC", |
| "npi": "1234567890", |
| "diagnosis_code": "M54.5", |
| "place_of_service": "11 - Office", |
| "submitted_date": "2024-03-20", |
| }, |
| }, |
| "CLAIM-008": { |
| "doc_type": "medicare_claim", |
| "title": "Medicare Claim #MC-2024-008", |
| "preview": "Patient P3387, Procedure 80053, Date 2024-03-19, $95.00", |
| "content": { |
| "claim_id": "MC-2024-008", |
| "patient_id": "P3387", |
| "patient_name": "Sandra Kim", |
| "procedure_code": "80053", |
| "procedure_desc": "Comprehensive metabolic panel", |
| "service_date": "2024-03-19", |
| "billed_amount": 95.00, |
| "provider_id": "PRV-4421", |
| "provider_name": "LabFirst Diagnostics LLC", |
| "npi": "5544332211", |
| "diagnosis_code": "E11.9", |
| "place_of_service": "81 - Independent Laboratory", |
| "submitted_date": "2024-03-23", |
| }, |
| }, |
| "CLAIM-009": { |
| "doc_type": "medicare_claim", |
| "title": "Medicare Claim #MC-2024-009", |
| "preview": "Patient P6612, Procedure 99215, Date 2024-03-21, $355.00", |
| "content": { |
| "claim_id": "MC-2024-009", |
| "patient_id": "P6612", |
| "patient_name": "Franklin Torres", |
| "procedure_code": "99215", |
| "procedure_desc": "Office visit – established patient, high complexity", |
| "service_date": "2024-03-21", |
| "billed_amount": 355.00, |
| "provider_id": "PRV-9908", |
| "provider_name": "Premier Health Associates", |
| "npi": "6677889900", |
| "diagnosis_code": "F32.1", |
| "place_of_service": "11 - Office", |
| "submitted_date": "2024-03-27", |
| }, |
| }, |
| "CLAIM-010": { |
| "doc_type": "medicare_claim", |
| "title": "Medicare Claim #MC-2024-010", |
| "preview": "Patient P1143, Procedure 90837, Date 2024-03-17, $175.00", |
| "content": { |
| "claim_id": "MC-2024-010", |
| "patient_id": "P1143", |
| "patient_name": "Helen Okafor", |
| "procedure_code": "90837", |
| "procedure_desc": "Psychotherapy, 60 minutes", |
| "service_date": "2024-03-17", |
| "billed_amount": 175.00, |
| "provider_id": "PRV-2255", |
| "provider_name": "Behavioral Health Partners", |
| "npi": "3344556677", |
| "diagnosis_code": "F41.1", |
| "place_of_service": "11 - Office", |
| "submitted_date": "2024-03-22", |
| }, |
| }, |
| } |
|
|
| TASK1_GROUND_TRUTH = { |
| "exact_duplicates": [("CLAIM-001", "CLAIM-002")], |
| "near_duplicates": [("CLAIM-001", "CLAIM-004")], |
| "clean_claims": ["CLAIM-003", "CLAIM-005", "CLAIM-006", "CLAIM-007", "CLAIM-008", "CLAIM-009", "CLAIM-010"], |
| } |
|
|
|
|
| |
| |
| |
|
|
| TASK2_DOCUMENTS: Dict[str, Dict[str, Any]] = { |
| "CONTRACT-001": { |
| "doc_type": "government_contract", |
| "title": "Federal Construction Contract #FC-2023-0847", |
| "preview": "FastBuild LLC awarded $2.3M for GSA facility renovation", |
| "content": { |
| "contract_id": "FC-2023-0847", |
| "vendor_name": "FastBuild LLC", |
| "vendor_ein": "47-3821044", |
| "award_amount": 2_300_000.00, |
| "award_date": "2023-08-12", |
| "project": "GSA Region 4 Facility Renovation – Atlanta", |
| "contracting_officer": "J. Williams", |
| "contracting_officer_id": "CO-4421", |
| "period_of_performance": "2023-09-01 to 2024-03-31", |
| "solicitation_type": "Sole Source – 8(a) Program", |
| "naics_code": "236220", |
| }, |
| }, |
| "CONTRACT-002": { |
| "doc_type": "government_contract", |
| "title": "Federal IT Contract #IT-2023-1102", |
| "preview": "FastBuild LLC awarded $890K for network infrastructure", |
| "content": { |
| "contract_id": "IT-2023-1102", |
| "vendor_name": "FastBuild LLC", |
| "vendor_ein": "47-3821044", |
| "award_amount": 890_000.00, |
| "award_date": "2023-11-03", |
| "project": "DOT Regional Office Network Upgrade", |
| "contracting_officer": "J. Williams", |
| "contracting_officer_id": "CO-4421", |
| "period_of_performance": "2023-12-01 to 2024-06-30", |
| "solicitation_type": "Sole Source – 8(a) Program", |
| "naics_code": "541512", |
| "note": "Outside vendor's primary NAICS code", |
| }, |
| }, |
| "VENDOR-REG-001": { |
| "doc_type": "vendor_registration", |
| "title": "SAM.gov Registration – FastBuild LLC", |
| "preview": "FastBuild LLC, Delaware LLC, EIN 47-3821044", |
| "content": { |
| "legal_name": "FastBuild LLC", |
| "dba": None, |
| "entity_type": "Limited Liability Company", |
| "state_of_incorporation": "Delaware", |
| "ein": "47-3821044", |
| "cage_code": "8FB21", |
| "uei": "FBLLC2023US", |
| "registered_agent": "National Registered Agents Inc", |
| "principal_address": "1209 Orange Street, Wilmington, DE 19801", |
| "primary_naics": "236220", |
| "8a_certified": True, |
| "8a_certifying_entity": "SBA Region 4", |
| "annual_revenue_reported": 180_000, |
| "employees_reported": 3, |
| "founded": "2022-11-14", |
| "note": "Annual revenue inconsistent with contract awards", |
| }, |
| }, |
| "STATE-FILING-DE-001": { |
| "doc_type": "state_corporate_filing", |
| "title": "Delaware Division of Corporations – FastBuild LLC", |
| "preview": "FastBuild LLC 100% owned by ConstructPro Inc", |
| "content": { |
| "entity_name": "FastBuild LLC", |
| "file_number": "DE-7734821", |
| "formation_date": "2022-11-14", |
| "registered_agent": "National Registered Agents Inc", |
| "members": [ |
| { |
| "name": "ConstructPro Inc", |
| "ownership_pct": 100, |
| "state": "Nevada", |
| "ein": "88-4421033", |
| } |
| ], |
| "manager": "ConstructPro Inc", |
| "status": "Active", |
| }, |
| }, |
| "STATE-FILING-NV-001": { |
| "doc_type": "state_corporate_filing", |
| "title": "Nevada Secretary of State – ConstructPro Inc", |
| "preview": "ConstructPro Inc owned by R. Holden Family Trust", |
| "content": { |
| "entity_name": "ConstructPro Inc", |
| "file_number": "NV-C20190044231", |
| "formation_date": "2019-03-22", |
| "registered_agent": "Nevada Corporate Services LLC", |
| "officers": [ |
| {"title": "President", "name": "Redacted per NV statute §78.150"}, |
| {"title": "Secretary", "name": "Redacted per NV statute §78.150"}, |
| ], |
| "shareholders": [ |
| { |
| "name": "R. Holden Family Trust", |
| "trust_state": "Delaware", |
| "ownership_pct": 100, |
| "trustee": "See trust documents", |
| } |
| ], |
| "status": "Active", |
| "note": "Nevada does not require disclosure of beneficial owners", |
| }, |
| }, |
| "TRUST-DOC-001": { |
| "doc_type": "trust_document", |
| "title": "R. Holden Family Trust – Declaration of Trust", |
| "preview": "Trustee: Raymond T. Holden. Beneficiaries include family members.", |
| "content": { |
| "trust_name": "R. Holden Family Trust", |
| "trust_state": "Delaware", |
| "trust_date": "2018-09-01", |
| "trustee": "Raymond T. Holden", |
| "trustee_address": "412 Magnolia Drive, Atlanta, GA 30301", |
| "beneficiaries": [ |
| {"name": "Raymond T. Holden", "relationship": "Grantor"}, |
| {"name": "Patricia Holden-Williams", "relationship": "Spouse"}, |
| {"name": "Derek Williams", "relationship": "Son-in-law"}, |
| ], |
| "assets": "All shares of ConstructPro Inc and affiliated entities", |
| }, |
| }, |
| "GOV-EMPLOYEE-001": { |
| "doc_type": "government_employee_record", |
| "title": "Federal Employee Record – CO-4421", |
| "preview": "Contracting Officer James Williams, GSA Region 4", |
| "content": { |
| "employee_id": "CO-4421", |
| "name": "James Williams", |
| "agency": "General Services Administration", |
| "region": "Region 4 – Southeast", |
| "title": "Senior Contracting Officer", |
| "gs_grade": "GS-14", |
| "office": "Atlanta Federal Center", |
| "start_date": "2015-06-01", |
| "financial_disclosure_filed": True, |
| "financial_disclosure_year": 2023, |
| "spouse_name": "Patricia Holden-Williams", |
| "note": "Financial disclosure does not list ConstructPro Inc or FastBuild LLC", |
| }, |
| }, |
| "INVOICE-001": { |
| "doc_type": "invoice", |
| "title": "Invoice INV-FB-2023-0092 from FastBuild LLC", |
| "preview": "FastBuild LLC invoices $2.3M – no itemized breakdown", |
| "content": { |
| "invoice_id": "INV-FB-2023-0092", |
| "vendor": "FastBuild LLC", |
| "bill_to": "GSA Region 4", |
| "contract_ref": "FC-2023-0847", |
| "invoice_date": "2024-03-28", |
| "line_items": [ |
| { |
| "description": "Facility renovation services – per contract", |
| "quantity": 1, |
| "unit_price": 2_300_000.00, |
| "total": 2_300_000.00, |
| } |
| ], |
| "total_amount": 2_300_000.00, |
| "payment_terms": "Net 30", |
| "bank_account": "Routing 021000021 / Acct 887743921", |
| "note": "No itemized labor or material breakdown provided", |
| }, |
| }, |
| } |
|
|
| TASK2_GROUND_TRUTH = { |
| "ownership_chain": [ |
| ("FastBuild LLC", "ConstructPro Inc"), |
| ("ConstructPro Inc", "R. Holden Family Trust"), |
| ("R. Holden Family Trust", "Derek Williams / Patricia Holden-Williams"), |
| ], |
| "conflict_of_interest": True, |
| "conflicted_officer": "James Williams", |
| "conflicted_family_member": "Patricia Holden-Williams", |
| "total_amount_at_risk": 3_190_000.00, |
| "violation_type": "shell_company", |
| "key_evidence": [ |
| "STATE-FILING-DE-001", |
| "STATE-FILING-NV-001", |
| "TRUST-DOC-001", |
| "GOV-EMPLOYEE-001", |
| ], |
| } |
|
|
|
|
| |
| |
| |
|
|
| TASK3_DOCUMENTS: Dict[str, Dict[str, Any]] = { |
| "ANON-TIP-001": { |
| "doc_type": "anonymous_tip", |
| "title": "Anonymous Whistleblower Tip #WT-2024-0033", |
| "preview": "Tip alleges MediSupply Corp overbilling CMS for durable medical equipment", |
| "content": { |
| "tip_id": "WT-2024-0033", |
| "received_date": "2024-01-15", |
| "allegation": ( |
| "MediSupply Corp has been systematically billing Medicare for " |
| "power wheelchairs (HCPCS K0831) at the highest reimbursement tier " |
| "regardless of patient need or physician documentation. " |
| "Many patients received standard manual wheelchairs or nothing at all. " |
| "The scheme has been ongoing since at least Q3 2022. " |
| "The billing manager, Karen Sloane, instructed staff to always select K0831." |
| ), |
| "tipster_relation": "Former billing department employee", |
| "estimated_fraud_amount": "Could be tens of millions", |
| }, |
| }, |
| "CMS-CLAIM-BATCH-001": { |
| "doc_type": "cms_claim_batch", |
| "title": "CMS Claims Extract – MediSupply Corp 2022-2024", |
| "preview": "847 claims for K0831 power wheelchair, $14.2M total", |
| "content": { |
| "provider": "MediSupply Corp", |
| "provider_npi": "3344556600", |
| "claim_period": "2022-07-01 to 2024-01-31", |
| "hcpcs_billed": "K0831", |
| "hcpcs_description": "Power wheelchair, group 3 heavy duty", |
| "total_claims": 847, |
| "total_billed": 14_200_000.00, |
| "medicare_paid": 11_360_000.00, |
| "avg_per_claim": 16_000.00 + (800_000 / 847), |
| "comparison_industry_avg_k0831_claims": 120, |
| "comparison_industry_avg_billed": 2_016_000.00, |
| "anomaly_flag": "Claims volume 7x industry average for provider size", |
| }, |
| }, |
| "CMS-CLAIM-BATCH-002": { |
| "doc_type": "cms_claim_batch", |
| "title": "CMS Claims Extract – MediSupply Corp K0001 comparison", |
| "preview": "Only 12 claims for K0001 standard manual wheelchair in same period", |
| "content": { |
| "provider": "MediSupply Corp", |
| "provider_npi": "3344556600", |
| "claim_period": "2022-07-01 to 2024-01-31", |
| "hcpcs_billed": "K0001", |
| "hcpcs_description": "Standard manual wheelchair", |
| "total_claims": 12, |
| "total_billed": 36_000.00, |
| "medicare_paid": 28_800.00, |
| "note": "K0831 to K0001 ratio is 70:1; industry norm is approximately 3:1", |
| }, |
| }, |
| "PHYSICIAN-ORDERS-001": { |
| "doc_type": "physician_orders", |
| "title": "Physician Order Sample – 50 random K0831 claims", |
| "preview": "38 of 50 sampled physician orders do not support K0831 level", |
| "content": { |
| "sample_size": 50, |
| "orders_reviewed": 50, |
| "orders_supporting_k0831": 12, |
| "orders_not_supporting_k0831": 38, |
| "orders_missing_entirely": 8, |
| "common_documented_needs": [ |
| "Ambulation assistance for moderate distances", |
| "Post-surgical mobility aid", |
| "Arthritis-related limited mobility", |
| ], |
| "k0831_clinical_requirement": ( |
| "Patient must have severe neurological or musculoskeletal condition " |
| "preventing any self-propulsion; requires detailed functional assessment" |
| ), |
| "finding": "76% of sampled orders do not meet K0831 medical necessity criteria", |
| }, |
| }, |
| "INTERNAL-EMAIL-001": { |
| "doc_type": "internal_email", |
| "title": "Internal Email Chain – Billing Department", |
| "preview": "Karen Sloane instructs staff to always bill K0831", |
| "content": { |
| "email_chain": [ |
| { |
| "date": "2022-09-14", |
| "from": "Karen Sloane <k.sloane@medisupply.example>", |
| "to": "Billing Staff <billing@medisupply.example>", |
| "subject": "Wheelchair billing – updated protocol", |
| "body": ( |
| "Team, going forward please select K0831 for all wheelchair " |
| "orders unless the physician specifically writes K0001. " |
| "K0831 reimbursement is significantly higher and we need to " |
| "hit our Q4 targets. If you have questions see me directly. " |
| "Do not put this in writing elsewhere." |
| ), |
| }, |
| { |
| "date": "2022-09-15", |
| "from": "T. Reyes <t.reyes@medisupply.example>", |
| "to": "Karen Sloane <k.sloane@medisupply.example>", |
| "subject": "Re: Wheelchair billing – updated protocol", |
| "body": "Understood. What if the doctor's order says standard?", |
| }, |
| { |
| "date": "2022-09-15", |
| "from": "Karen Sloane <k.sloane@medisupply.example>", |
| "to": "T. Reyes <t.reyes@medisupply.example>", |
| "subject": "Re: Re: Wheelchair billing – updated protocol", |
| "body": "Bill K0831 anyway. We'll say it was a clerical upgrade.", |
| }, |
| ], |
| }, |
| }, |
| "PATIENT-COMPLAINT-001": { |
| "doc_type": "patient_complaints", |
| "title": "CMS Patient Complaint Log – MediSupply Corp", |
| "preview": "23 complaints: received wrong equipment or no equipment", |
| "content": { |
| "complaints_reviewed": 23, |
| "complaint_period": "2022-07-01 to 2024-01-31", |
| "complaint_types": { |
| "received_manual_wheelchair_billed_for_power": 9, |
| "received_no_equipment_but_medicare_billed": 7, |
| "received_different_model_than_billed": 5, |
| "billing_dispute_other": 2, |
| }, |
| "sample_complaint": ( |
| "Patient ID P7741: Was told she qualified for a power wheelchair. " |
| "Received a manual chair. Medicare was billed $16,500 for K0831. " |
| "Her doctor never ordered a power wheelchair." |
| ), |
| }, |
| }, |
| "CORPORATE-FILING-001": { |
| "doc_type": "corporate_filing", |
| "title": "MediSupply Corp – Delaware Certificate of Incorporation", |
| "preview": "MediSupply Corp incorporated 2020, CEO Richard Poole", |
| "content": { |
| "entity_name": "MediSupply Corp", |
| "ein": "61-4421887", |
| "state": "Delaware", |
| "incorporated": "2020-02-18", |
| "registered_agent": "The Corporation Trust Company", |
| "officers": [ |
| {"title": "CEO", "name": "Richard Poole"}, |
| {"title": "CFO", "name": "Sandra Poole"}, |
| {"title": "Billing Manager", "name": "Karen Sloane"}, |
| ], |
| "cms_provider_enrollment": "Active – Enrolled 2020-06-01", |
| "medicare_provider_number": "33-4455660", |
| }, |
| }, |
| "REIMBURSEMENT-POLICY-001": { |
| "doc_type": "cms_policy", |
| "title": "CMS LCD L33702 – Power Mobility Devices", |
| "preview": "K0831 requires documented severe functional limitation", |
| "content": { |
| "lcd_number": "L33702", |
| "title": "Power Mobility Devices – Coverage Criteria", |
| "effective_date": "2020-01-01", |
| "k0831_criteria": [ |
| "Severe neurological condition (e.g., ALS, MS, SCI) OR", |
| "Severe musculoskeletal condition preventing any self-propulsion", |
| "Face-to-face evaluation by treating physician documenting functional limitation", |
| "Seven-element order from physician within 45 days of evaluation", |
| "Home assessment confirming power wheelchair can be used in the home", |
| ], |
| "k0831_rate_2023": 16_488.00, |
| "k0001_rate_2023": 3_000.00, |
| "difference": 13_488.00, |
| "false_claims_implication": ( |
| "Billing K0831 without meeting coverage criteria constitutes " |
| "a false claim under 31 U.S.C. §3729(a)(1)(A)" |
| ), |
| }, |
| }, |
| "FINANCIAL-RECORDS-001": { |
| "doc_type": "financial_records", |
| "title": "MediSupply Corp – Bank Records Summary 2022-2024", |
| "preview": "Medicare payments of $11.36M deposited; large transfers to Poole family LLCs", |
| "content": { |
| "institution": "First National Bank", |
| "account_holder": "MediSupply Corp", |
| "period": "2022-07-01 to 2024-01-31", |
| "medicare_deposits": 11_360_000.00, |
| "transfers_out": [ |
| { |
| "recipient": "Poole Ventures LLC", |
| "amount": 4_200_000.00, |
| "description": "Management consulting fees", |
| }, |
| { |
| "recipient": "Coastal Properties LLC", |
| "amount": 2_100_000.00, |
| "description": "Lease payments", |
| }, |
| { |
| "recipient": "Personal account – R. Poole", |
| "amount": 1_800_000.00, |
| "description": "Salary distributions", |
| }, |
| ], |
| "note": "Poole Ventures LLC and Coastal Properties LLC are owned by Poole family members", |
| }, |
| }, |
| "EXPERT-ANALYSIS-001": { |
| "doc_type": "expert_analysis", |
| "title": "Independent DME Billing Expert Report", |
| "preview": "Expert estimates $8.2M in improper Medicare payments to MediSupply Corp", |
| "content": { |
| "expert": "Dr. Judith Kwan, CPC, CPMA", |
| "methodology": ( |
| "Reviewed 847 K0831 claims, sampled 50 physician orders, " |
| "applied CMS LCD L33702 criteria to determine medical necessity compliance" |
| ), |
| "findings": { |
| "non_compliant_claims_estimated_pct": 76, |
| "estimated_non_compliant_claims": 644, |
| "avg_overpayment_per_claim": 12_744.00, |
| "total_estimated_overpayment": 8_207_136.00, |
| "treble_damages_fca": 24_621_408.00, |
| "civil_penalties_per_claim": "Between $13,946 and $27,894", |
| }, |
| "conclusion": ( |
| "The billing pattern is inconsistent with any legitimate clinical practice. " |
| "The internal email chain confirms intentional upcoding. " |
| "This constitutes a violation of 31 U.S.C. §3729(a)(1)(A) and (B)." |
| ), |
| }, |
| }, |
| } |
|
|
| TASK3_GROUND_TRUTH = { |
| "defendant": "MediSupply Corp", |
| "defendant_individuals": ["Richard Poole", "Karen Sloane"], |
| "violation_type": "fca_violation", |
| "violation_statutes": ["31 U.S.C. §3729(a)(1)(A)", "31 U.S.C. §3729(a)(1)(B)"], |
| "amount_at_risk_min": 8_000_000.00, |
| "amount_at_risk_max": 11_400_000.00, |
| "key_evidence": [ |
| "INTERNAL-EMAIL-001", |
| "CMS-CLAIM-BATCH-001", |
| "PHYSICIAN-ORDERS-001", |
| "ANON-TIP-001", |
| ], |
| "scheme": "upcoding_dme", |
| "treble_damages": 24_621_408.00, |
| } |
|
|
