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Marcelino Rodriguez, CFE

Cell Telephone 305-***-****

ad0gdg@r.postjobfree.com

PROFILE

Former Senior Special Agent and Criminal Investigator with the US Secret Service and the OIG, US Department of Labor, Office of Investigations.

Certified Fraud Examiner since 2006

Graduated from the U.S. Treasury Law Enforcement Agent School.

Graduated from the U.S. Secret Service Law Enforcement Agent School.

Conducted interviews of providers, beneficiaries, and witnesses as part of the investigative process.

Experienced dealing with reporting requirements to regulatory agencies such as Medicare, Medicaid, Affordable Care Act, Commercial Insurance, OPM and Department of Insurance Fraud

Prepared in conjunction with the Compliance Officer an Anti-Fraud plan to conduct fraud investigations to detect and prevent incidents of fraud and to coordinate investigations with enforcement agencies understanding organizational strategies and objectives of related areas. Respond to allegations of violations of rules, regulations, Code of Conduct and recommending initiation of investigations.

Experienced in training employees in Healthcare FWA and in Compliance.

Identified more than $12 million dollars in overpayments because of inappropriate claims.

Trained and experienced in SIU investigations, Healthcare FWA, and following the Anti-Fraud Plan, able to work independently and manage caseload assigned.

Implemented actions to include placing providers on pre-payment status, payment suspension and revocation of provider participation in healthcare programs.

Conducted onsite audits/reviews of provider records to ensure proper billing practices and prepared investigative and other reports of a complex nature and include summaries that present metrics, schemes, trends, and evidence to superiors and stakeholders to include enforcement agencies.

Served in the US Army during hostilities with IRAQ serving in the combat zone and awarded a Bronze Medal. Specialized as a Chief, Finance Operations NCO.

Conducted a training seminar for fraud investigators in Diagnostic Fraud for the National Healthcare Anti-Fraud Association (NHCAA) during annual conference in Las Vegas.

Conducted a training seminar in Diagnostic Fraud for all the CMS regions in the United States.

Management experience of more than fifteen (15) years to include supervision of investigators.

Extensive experience with fraud, waste and abuse detection and claims data analysis

Wide knowledge of law involving healthcare Commercial Plans, Medicare/ Medicaid fraud, waste, and abuse detection

Proficient in data analysis and ensure that the department meets the required OIG programs and responding to issues and concerns identified.

Excellent verbal and written communication skills

Ability to differentiate between fraud, abuse, and overutilization.

Bilingual in English and Spanish.

WORK EXPERIENCE:

SIU Investigator. From October 2020 to October 2022. Health Alliance Plan, Troy, MI. Conducted investigations in Healthcare Fraud, Waste and Abuse (FWA) and matters that involve risk and compliance. Analyzed data to determine possible incidents of FWA in all lines of business. Interview complainants that reported incidents and events using the Hotline and other means to determine and clarify complaints for further investigations or referrals to appropriate departments. Interview providers and contractors to determine evidence of FWA. Prepare reports of interview and reports of investigations for appropriate action.

Independent Contractor. September 2017 through January 2019.

Worked sporadically as a Consultant with Fraudscope, Inc., Atlanta, Georgia, assisting principals in the development of a platform dedicated to uncovering healthcare fraud, waste, and abuse. Worked with Data Scientists in the development of the platform and analyzed data to detect areas of possible fraud, waste, and abuse. Made recommendations as to items that should be included on the spreadsheet to enable Investigators to analyze claims data without any waste of time. Conducted periods of instructions concerning fraud, waste, and abuse.

Jackson Health Plan (March 2013-March 29, 2014) Healthcare Fraud, Waste and Abuse Officer/SIU.

Directed the FWA and SIU activities involving all lines of business to include Medicare Part C, Part D, Medicaid, and Commercial Insurance. Presented mandatory FWA training to employees. Prepared in conjunction with the Compliance Officer an Anti-Fraud plan to set guidelines to prevent and identify incidents of FWA. Was a member of the Executive Compliance Committee and reported incidents of FWA and implemented a strategy to detect and prevent FWA. Prepared reports to regulatory agencies as part of the Compliance requirements. Review call center data and opened investigations concerning FWA. Monitored the Fraud Hotline and initiate action based on calls. Reported incidents to AHCA/MPI and prepared reports on Suspected/Confirmed instances of Fraud and Abuse, Quarterly Fraud and Abuse Reports. (QFAAR) and Annual reports. Conducted investigations based on allegations of services not rendered, duplicate billing and medical necessity issues Investigated issues dealing with unlicensed individuals. Conducted on-site reviews.

Catapult Consultants (July 2012 to February 2013)

Employed by a Business Integrity contractor. Conducted investigations of fraud, waste, and abuse in the area of Medicare and Medicaid.

Performed investigations, audits, evaluations, and inspections regarding the delivery of and payment for health care.

Assisted the implementation of the civil, criminal, and administrative statutes applicable to health care.

Provided industry assistance, including suggested opinions, safe harbors and specific fraud alerts regarding to fraudulent health care practices.

Prepared Reports of Investigations detailing material and relevant evidence.

Conducted joint investigations with federal and state law enforcement agents.

Presented oral and written reports to Senior Managers and Directors as well as to state and federal prosecutors.

Issued letters requesting reimbursements for inappropriate claims.

Analyzed data and perform on-site reviews of medical records.

Analyzed data concerning claims. Made determination as to the appropriateness of claims.

Presented reports and referred issues to law enforcement for legal action.

Magellan Health (December 2011 to July 2012) Investigator, Miami, Florida.

Conducted investigations dealing with fraud, waste, and abuse in Mental Healthcare sponsored by state Medicaid programs and private insurance carriers.

Analyzed claims and medical records to determine appropriateness of claims and submitted reimbursement request for overpayments.

Presented oral and written reports to Senior Managers and Directors as well as to state and federal prosecutors.

Issued letters requesting reimbursements for inappropriate claims.

Analyzed data and perform on-site reviews of medical records.

Analyzed data concerning claims. Made determination as to the appropriateness of claims.

Presented reports and referred issues to law enforcement for legal action.

Office of the Attorney General, State of Florida (March 2011 to December 2011) Investigator.

Review documents, research internet and prepare investigative file for Special Counsel and Assistant Attorney General to engage in negotiations with entities violating security breach statutes and or engaged in fraudulent and deceptive practices related to Healthcare medications and substances.

Assisted Special Counsel in matters of multi-state investigations affecting consumers.

OTHER EXPERIENCE: Served for over 20 years as a Special Agent, Criminal Investigator with the US Secret Service and Special Agent with the Office of Inspector General of the US Department of Labor, Office of Labor Racketeering, Office of Investigations. Conducted investigations related to rules and regulations dealing with employee benefit plans, fiduciary standards, prudent man rule, Federal Employee Compensation Act, bribery of government officials accepting things of value in exchange for official acts. Time and attendance fraud, expense voucher false claims, misuse of government vehicles and misuse of government property. Testified before grand and petit jurors, arrested individuals suspected of being involved in felonies. Served grand jury and administrative subpoenas. Review financial records to uncover embezzlement and conversion of assets. Assisted other law enforcement officers in joint investigations. Worked as an undercover agent infiltrating individuals and groups engaged in criminal activities.

Served in the US Army and deployed during Desert Storm operations in Southwest Asia. Served in the US Army Reserve until 2002. Served in the capacity of Finance Operations Sergeant Major. Was awarded a Bronze Star and Army Commendation Medal for exemplary service while under a hostile environment during Desert Storm. Conducted operations dealing with Budget operations to include assignments, appropriations, and expenditure of funds. Conducted accounting and charged disbursements to proper accounting classifications. Ensure expenditures were proper and for the purpose that they were authorized.

EDUCATION.

Catholic University of Puerto Rico

Bachelors in Business Administration

Certified Fraud Examiner (CFE) No. 121722

Specialized Training:

Criminal Investigations, US Department of Treasury

Investigations US Secret Service

Healthcare Fraud Investigations

Provider Fraud Investigation

Beneficiary Fraud Investigations

Broker Fraud Investigations

Employee Integrity Investigations

White Collar Crime Investigations

Contract Fraud

Rules of Evidence

Conflict of Interest

CPT and ICD training

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