The best part of talking to people who work in fraud investigations is listening to the stories they tell about how they detected the crimes and helped to bring the fraudsters to justice. They’re a passionate bunch and, while each one probably has a different reason for getting into the field of fraud detection, they have a common outlook on our responsibility to do what’s right. It’s not surprising, as they’ve probably come across a lot of unethical behavior, judging by the number of high-profile fraud cases in the news every week.
In the Trenches
But alongside the high-profile fraud cases are thousands of others under investigation by equally dedicated teams, restoring millions of dollars back into the programs from which they are being siphoned.
Suzette Long, Consulting Manager at Thomson Reuters, has a soft spot for children and the instances she has encountered where health care fraud has put children into dangerous circumstances have stayed with her for years. One such case was a Louisiana dentist who came to Long’s attention when she was data mining for unusual billing.
“I noticed that he was billing for nitrous oxide for every patient. In addition he was doing volumes of dentistry that didn’t make sense. So rather than request the records by mail, we did an on-site to get the records,” says Long.
“In addition to doing that, I had asked them to check to make sure he had a centrally installed nitrous oxide system, because with the volume he was billing, I knew he couldn’t just have a portable roll-around system,” she says. The on-site analyst forgot to check for the installed system until he was on his way out, at which point he asked the receptionist if they had one and she confirmed that they did.
“Two days later I started checking his claims and he was actually voiding out some nitrous claims,” says Long. “So I thought he had figured it out. But when I looked closer, he was only voiding out these ones that had been billed by a Russian associate who had been with him, but who had left,” she said.
Long called the Attorney-General’s office to report her findings, and two weeks later found herself on a stake-out, with a court order from a judge. “We set up and secured the office at 6am with a box of donuts,” she says. “The FBI was also looking at him for drug abuse, so we had two FBI agents, six Attorney General’s agents, all carrying weapons.” When the receptionist showed up, the team went into action.
“All ten of us descended upon this poor little girl, who was now sweating,” says Long, who was posted at the front desk to ensure the receptionist didn’t touch the computer.
“Prior to this, we had interviewed some ex-employees and patients so we had gotten validation from some patients that they had never had nitrous oxide, and we had also found out from employees that he typically came to work late, because he didn’t like to be there when the kids were screaming and yelling. He preferred them to be sedated when he got there, which was another area of concern for me,” she says. “At this point in the investigation, the fact that he didn’t have nitrous oxide and was billing for it was not what I was overly concerned about. More of a concern was the safety of the kids.”
Despite frantic calls from the receptionist, the dentist never appeared at the office, but the search warrant revealed that he didn’t have nitrous oxide. The team interviewed the Russian dentist, who revealed that he had never used, and wasn’t even licensed to use, nitrous oxide.
“And it was billed on every claim, so we put two and two together and realized the reason he was voiding the claims was because he thought we were onto the fact that he was billing it for an unlicensed dentist,” says Long.
But far more worrying were the revelations during the investigation that the dentist was sedating and restraining children unnecessarily. Later examinations with 20 of the children revealed that they had been traumatized by their experiences at the dentist.
“My passion for the case had nothing to do with the fact that he was billing for nitrous oxide,” says Long. “He was harming children in the process of trying to make money out of the Medicaid program. That’s when Medicaid fraud crosses the line.”