Nuts & bolts of health care fraud examinations

Health care fraud examinations can be laborious. Discovery of evidence can be elusive. You need the most reliable sources and resources. Here’s a practical sampling of some of the best places to start from a fraud examiner who’s worked scores of cases.

Excerpted and adapted from Healthcare Fraud Investigation Guidebook, CRC Press, by Charles E. Piper, CFE, pages 85-97. Available at the ACFE Bookstore, Amazon.

Years ago, I conducted a highly complex financial fraud examination of a contractor. I relied on an experienced auditor and accountant to review and analyze cost and expense reports. He was patient and better at the numbers than me. Because of his expertise in accounting, I later asked him to review a list of questions I planned on asking the chief financial officer (CFO) of the suspect company. The auditor said, “We don’t need to ask these questions because we already know the answers to them.”

What the auditor didn’t understand was that we weren’t playing a game of “whodunit?” Although we already knew the answers to the questions, that was immaterial. I was trying to put together a strong case in which information could be corroborated by several different sources. By corroborating the information, I (and a potential jury) could be confident that 1) the information was accurate and 2) the suspect’s defense attorney would have a more difficult time trying to refute the information. In short, the more sources from which you obtain the same information, the more likely that information will be considered credible and reliable.

This is just one of the many lessons fraud examiners can learn when conducting health care fraud examinations. Fraud examiners might have access to numerous sources and resources, so it’s important to know how and when to use them. In the case above, I used the help of an auditor (my resource) to glean enough information to put together a proper list of questions for the suspect company. And while his approach to interviewing didn’t match mine, fraud examiners should collaborate when working to their end goals.

Information you want and need is often available from more than one source. Of course, you’ll consider some sources more reliable than others, and some will be the “most reliable.” But don’t make the mistake of thinking there’s only one place to legally obtain the documentation and/or information you need. Sometimes investigators tend to think “either or” when they could or should be thinking, “both,” “many” or “all of the above.” Obtaining information from more than one source helps corroborate that information.

Health care fraud examinations, as I discovered early, can be grueling ordeals. So, I want to share some of the nuts and bolts of sources and resources I’ve used in the many cases I’ve worked.