Catching the Little Fish that Got Away

Protect yourself against small-time frauds by insured subscribers.

By Paul D. Kimball, CFE

When it comes to healthcare fraud, most Special Investigations Units (SIUs) within insurance companies focus on the recipients of the largest benefits: the healthcare providers. Scams committed by this faction often are serial and result in huge monetary losses. As fraud examiners, we intrinsically "follow the money."

But what about the patients, or insured subscribers, who defraud the system? These perpetrators typically swindle smaller amounts of money and are one-time offenders. Because the monetary losses typically are minimal and the cases often cost more to resolve than what will be recovered, many fraud examiners place these cases on "the back burner" in favor of the larger, serial crimes of the crooked providers. But there's a flaw in this approach. Consider the following analogy.
Bream fishing is a popular activity across much of the country and one that I particularly enjoy. Sometimes, as fast as you can put the bait in the water, the little fish will jerk your line downward and nibble away at the bait. What you want, however, is the larger fish that swim at the bottom of the lake, so you pull up your empty hook and bait it again, hoping to sneak past the less-rewarding catch the next time around. Over time, you manage to hook a few more of these little fish, but you throw most of them back without giving them much thought. They're not worth your time.

When you left the bait shop, you had about 100 crickets. You expected this to last most of the day, but before you know it, you have no more crickets and only a couple of large fish. You begin to understand that all those little fish you've dismissed have caused real damage.

Does this sound familiar? Are you responding to insured subscriber fraud only after the fraud has become significant? Many wayward subscribers defraud insurance companies only once to fulfill an immediate or short-term need, but sometimes individuals find it too easy to make quick cash and they become serial offenders. That's when these small "fish" become embarrassingly large. As SIUs, we need to consider ways to catch these menacing minions before they get away.
Sometimes it's a happenstance discovery of a serial case that makes you reconsider your approach to insured subscriber fraud. As you read the following case example, consider what policies your SIU has in place right now to detect this type of activity. Could this happen to you?






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