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
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
• Primary source data
• Current and historical content (“way back” capability for Date Of Service)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.
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.
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.
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
TAKE WHAT YOU HAVE LEARNED AND:
• Modify/Update existing controls
• Add new controls