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Ramon Hernandez
Disclaimer: This report is a statistical analysis of publicly available Medicare data.
The anomalies identified herein do not necessarily constitute findings or accusations of fraud.
Statistical deviation from peer benchmarks may have legitimate clinical or business explanations.
All patterns warrant further investigation and independent verification.
Composite Score
59.5
Risk Classification
watchlist
Anomaly Signals
3
Analysis Period
2021–2023
Executive Summary
Hernandez is a General Practice provider in FL whose Medicare billing patterns exhibit statistically significant anomalies across 5 distinct fraud dimensions, consistent with the submission of false claims totaling approximately $152,966. Most critically, this provider submitted Medicare claims during a period of active OIG exclusion — a per se violation of 42 USC 1320a-7 that renders every post-exclusion claim false as a matter of law. This exclusion is independently confirmed by 3 of 5 sources checked: OIG LEIE <a href="#source_leie" color="#1a6dcc">[OIG LEIE]</a>, CMS Part B billing records <a href="#source_partb" color="#1a6dcc">[CMS Part B Utilization]</a>. See Exhibit G2 for full cross-verification. Billing volume analysis reveals service counts that exceed the physically deliverable capacity for this specialty, suggesting claims for services that could not have been rendered. The provider's beneficiary-to-service ratio significantly exceeds specialty peers, consistent with billing for patients not actually seen. Statistical analysis against General Practice peers in FL identified significant deviations in: volume anomaly. Practice structure analysis reveals organizational patterns consistent with schemes designed to obscure billing volume or bill through entities that lack sufficient documented providers. These patterns map to 4 strong fraud theories under the False Claims Act: Phantom Billing, Excluded Provider Billing, Ghost Patient Scheme.
Key Findings
- Total billing volume is a statistical outlier among specialty peers
- Medicare billing activity detected during OIG exclusion period
- Provider reassigned to multiple group practices with aggregate billing exceeding individual thresholds
BILLING ANOMALY ANALYSIS — Detailed statistical breakdown across 3 independent signals.
Peer comparison data showing deviation from specialty benchmarks. Financial impact assessment
with estimated overpayment calculations. Timeline and trend analysis showing multi-year patterns.
Prescribing analysis with controlled substance review. Industry payment correlation analysis.
Evidence strength assessment with corroboration matrix. Entity resolution findings.
Legal framework mapping to applicable False Claims Act provisions.
FINANCIAL IMPACT ASSESSMENT — Estimated single damages calculation. Treble damage projection
under 31 U.S.C. 3729. Per-claim civil penalty estimates ($13,946 to $27,894 per false claim).
Recovery breakdown by anomaly category.
PEER COMPARISON — Provider vs. specialty median, 90th percentile, and 95th percentile across
payment per service, services per beneficiary, and high-complexity coding ratio.
Data Sources: CMS Medicare Provider Utilization & Payment Data (Part B, 2021–2023),
CMS Part D Prescriber Data (2021–2023), CMS Open Payments (2021–2023),
HHS-OIG LEIE Exclusion List, NPPES NPI Registry. All data is publicly available.