John P. Benson Presents Anti-Fraud Basics at NHCAA

AVOID FRAUD EXPOSURE

5 basic steps to avoid fraud exposure through fraud detection and prevention.

Presented at the NHCAA 2017 Annual Training Conference

by John P. Benson, JC, AHFI, DFE, CIFI

Foundation of Preserving the Basics of Fraud Prevention

• Decide where to invest resources.

There is no re-do. Time and money ill-spent, compounds the problem.

• “Magic” bullets don’t exist.

Continual investment in that which does not work is its own form of fraud.

• Follow the money (FTM).

Pursue fraud like you know what you’re doing.

1. PREVENT FRAUD EXPOSURE

DESIGN  AND IMPLEMENT CONTROLS

For example: Deny payment on al claims that:

• Have a deactivated or mismatched NPI.

• Have a mismatched or missing TIN (FEIN or SSN).

• Have an invalid or inactive professional license for date of service.

Other data elements to invalidate a claim:

• DEA Registrant (by schedule)

• PECOS Enrollment

• Exclusion / Debarment

Gatekeeping requires:

• Primary source data

• Accuracy

• Current and historical content (“way back” capability for Date Of Service)

• Verify providers BEFORE they are in the system.

• Monitor providers continuously for adverse behavior and expirations.

• Access real-time data to approve or deny transactional reimbursement.

2. DETECT

QUERY AND THEORY

• Query to theory.

• Follow the money.

• Forget about predictive analytics and artificial intelligence, predictive analytics and artificial intelligence cannot tell you that a single claim is abuse, potential fraud or wasteful.

• PA and AI may help with probability, but we are not in the gambling business.

3. INVESTIGATE

DETAIL, DETAIL, DETAIL

• Build an investigative plan based on your theory.

• Be prepared to alter your theory. (Investigate the case, don’t make your case based on your original theory.)

• Interview everyone.

• Capture witness statements, investigate the witnesses as well.

• Secure physical and documentary evidence. Be mindful of chain of custody.

• Do everything to prove intent.

• Include anything a potential defendant could use to exculpate him/herself—hide nothing.

4. PROSECUTE

BUILD A DOCUMENTED REFERRAL TO LAW ENFORCEMENT OR FOR LEGAL COUNSEL

• COVER SHEET: Headers and basic information.

• TABLE OF CONTENTS: Make everything easy to find.

• FIRST SECTION: Documented Referral of [name], Suspect/Claimant/Defendant Information: name (aka’s), address, telephone number, DOB, SSN, DL, description, Claim Number(s), Date of Injury, Name of Insurance Carrier: address, telephone number, Policy Number(s), Carrier Contact: name, address, telephone number, Insured: name, address, telephone number, Insured Contact, Loss: dollar amount of crime (may be broken down by reserves plus costs)

• SECOND SECTION: One paragraph for case SYNOPSIS, including a sub-section on date of notice addressing statute of limitations issue.

• THIRD SECTION: CASE DETAIL

• FORTH SECTION: TIMELINE: Use a timeline-type program to provide a VISUAL timeline of events and if you have the technology, include some basic link analysis where appropriate (relationship linking).

• FIFTH SECTION: SUMMARY OF EVIDENCE: List all charges and describe all evidence proving up the elements of the charges (BAJI instructions are helpful). Include chain of custody data.

• SIXTH SECTION: MATERIALITY

• SEVENTH SECTION: WITNESS LIST: Include all identifying and location information for each witness and any background information, date(s), witness was interviewed and a short summary of what each witness will testify to.

• EIGHTH SECTION: PHYSICAL/DOCUMENTARY EVIDENCE LIST: Catalogue of all physical/documentary evidence cross referenced as an exhibit if included in the prosecution summary.

• NINTH SECTION: Exhibits

Criminal: Beyond a Reasonable Doubt

Civil RICO: Clear and Convincing or

Preponderance of the Evidence,

MUST PROVE CAUSATION

Civil Fraud: Clear and Convincing or

Preponderance of the Evidence

5. ASSESS

TAKE WHAT YOU HAVE LEARNED AND:

• Modify/Update existing controls

• Add new controls

Written by Susen Sawatzki Healthcare Industry Expert Muse. Writer. Publisher. Producer. Creator of Inspiring Narratives. Connect with Susen on LinkedIn