PRIVATE INVESTIGATORS’ ROLE IN HANDLING HEALTH CARE FRAUD

PRIVATE INVESTIGATORS’ ROLE IN HANDLING HEALTH CARE FRAUD

One of the areas with an increasing amount of fraud is the health sector. The situation seems to grow worse as the year goes by. There is a continuous rise in the reported cases of health insurance fraud. Hence, it is pertinent to identify the problem and identify possible solutions.

One major problem faced in a case of healthcare fraud is being able to prove that there is a possible fraud in the first place. This is because the plan to defraud usually includes the beneficiary and the medical practitioner. Over time, it has been ascertained that a useful tool for solving cases regarding healthcare fraud is retaining private investigators.

What is Health Care Fraud?

Healthcare fraud occurs when an individual or set of individuals decide to consciously make false claims to receive benefits from the healthcare system or an insurance agency. The fraud can be perpetrated by patients, medical professionals, and/or other persons who seek to benefit from the rewards.

According to estimates by the Federal Bureau of Investigation (FBI), Health Care Fraud Costs American taxpayers about $60-80 Billion + per year.

Private Investigators and Health Care Fraud

Private investigators as earlier mentioned can be effective in the investigation of health care fraud. They do so by studying documents and evidence available for their perusal. They also conduct interviews for suspected medical practitioners and patients as well as keep surveillance on all parties tied to the fraud. Insurance companies who have been defrauded with false health care claims, usually employ the services of private investigators to help in solving these cases.

Private investigators employ a series of methods in identifying points of falsehood in health care fraud, and they usually include surveillance, research, background check, review of documents, conducting interviews, gathering evidence, and assisting in increasing internal controls.

Surveillance

Surveillance is one of the most important, efficient, and basic skills in a private investigator’s skillset. This is because of the possibility of rendering pictures and video coverage as evidence in resolving a case. Surveillance could help in revealing someone who claims to be incapacitated by serious injuries while climbing up a ladder for a gutter/roof repair. It could also reveal a person making exchanges with his medical practitioner following a fraud claim. It could also exposes someone who was walking fine but then suddenly starts limping as they approach the doctor’s office. Hence, surveillance is a great tool for exposing fraud first-hand.

Research

Private investigators can also make research on claims presented by a beneficiary. They can scrutinize documents submitted for billings or other documents related to health care fraud. They can also go as far as backtracking the history of a claim to ascertain falsehoods as well. In researching fraud, private investigators make sure to pay attention to details.

Background Check

While working on fraud cases, private investigators may also conduct background checks on the parties tied to the claim. This is to ascertain if they have a history of making claims or if they have been part of fraud cases before. Background checks can also help in revealing the financial position of a claimant. A poor financial position might be a motivation for laying claims, while a good financial position with obscure sources might point towards some form of illegality.

Document Review

A proper review of documents by private investigators can also review falsehoods in a claim. At times, it could be that the document submitted as a doctor’s report was falsified.

Conduct Interviews

Private investigators can also conduct interviews with parties tied to possible healthcare fraud. Interviews can help in revealing falsehood in the feedback of the interviewees. Trained private investigators can usually tell when a person is telling lies or covering the truth.

Gather Evidence

The essence of implementing the techniques in the first place is to gather evidence. Evidence gathered is used to prove falsehood in a health care claim. The evidence could include related documents, pictures, and video coverage.

Assisting To Increase Internal Control

Increasing internal control is more efficient in preventing health care fraud. Private investigators could work with insurance companies to increase their internal control measures. Newly established measures could be based on past experiences of fraudulent claims.

Forms of Healthcare Fraud

Some techniques employed in defrauding insurance agencies and the health care system include personal injury claims, presenting bills for services not provided, upcoding of services, upcoding of items, making duplicate claims, excessive services, unnecessary services, and kickbacks.

Personal Injury Claims

Of the above-mentioned forms of healthcare fraud, a personal injury claim is one the most common. There are cases where healthcare fraud arising from personal injury claims could include an attorney, his client, and medical personnel. It is not an uncommon thing to find a personal injury attorney sending cases to their favorite chiropractor or orthopedic surgeon. In this case, the attorney is fully aware that the medical practitioner will write up a report that favors the attorney’s client so the client can get a favorable settlement.

Presenting Bills for Services Not Provided

Claimants might present bills for services that were never provided to Medicare, for instance, just to get unwarranted benefits.

Upcoding of Services and Items

There are cases where claimants could present bills for more costly services or medical equipment other than the ones received.

Duplicate Bills

By duplicating bills, claimants can alter original bills such as changing the date, just to charge twice for a service already rendered.

Excessive And Unnecessary Services

Excessive services involve presenting bills- perhaps to Medicare- for services greater than what was received. Unnecessary services, on the other hand, refer to the filing of a claim for a service that is not related to a patient’s condition.

Kickbacks

Kickbacks involve persuading medical practitioners with gifts so they can use unrequired services in pursuance of making a fraudulent claim.

Conclusion

Healthcare fraud has eaten deeply into the system, and the government as well as taxpayers are suffering the negative effect.

Private investigators are great personnel to use in resolving frauds such as this because they are specialized in what they do. While employing a private investigator to handle a healthcare fraud, you’ll want to confirm that they are experienced in such cases and can handle it while returning provable results.

About the Author

Chris Cavallo has been involved in every facet of the Security and Investigations Industry for over 40 years. He started his career with the two largest Security and Investigation Companies in the world at the time, Wells Fargo Guards Services and Pinkerton’s Investigative Services. After spending 2 years as a Management Trainee with 11 months in the field as an Undercover Operative he quickly raised rose through the ranks and became one of the most highly recognized Security Consultants for the next 10 years. Chris is considered a subject matter expert in various Security/Investigative practices such as Security Guard Services, Surveillance and Background Investigations. He ended is career with a Fortune 50 Company as the VP of the SE Region. He then co-founded a company, RSI Investigations (Records Search Inc.), which was one of the pioneers and leaders in the Background Screening industry in the late 80’s prior to accessing county records online. After this experience Chris founded Cavallo Associates working with Security, Defense and Investigation Companies and helping them develop their Business Plans and training their personnel while opening new markets in such places as Rome, Italy, several Central America countries and Bogota, Colombia. Today Chris is a Florida Licensed Private Investigator and Security Consultant and continues to dedicate himself in both the Security and Investigations Industry. Presently he is mentoring, developing and sponsoring several PI Interns and overseeing the CSI Security Business while specializing in Insurance Fraud cases as well. Both business units operate under the brand name CSI Secure Solutions headquartered in Davie Florida with offices in Bogota, Colombia. Chris lives in South Florida and is a community activist while being the Founder of The Robin Foundation.

 

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