By developing a strong working partnership with law enforcement on health insurance fraud cases, special investigations units can work more knowledgeably and effectively. They may be able to build better cases and recover more money. This relationship also may give law enforcement a sense of commitment and confidence about dealing with insurers, along with a helpful working knowledge of how they operate.
FierceHealthPayer: Anti-Fraud recently interviewed two field experts to get their best advice on how payers can improve relationships with law enforcement to serve the mutual interests of both. Ralph Carpenter (pictured below) is director of the SIU at Aetna, chair of the Board of Directors for the National Health Care Anti-Fraud Association (NHCAA) and a retired Connecticut State Police Lieutenant Colonel. Christine O'Neill is the supervisory special agent of the FBI's Boston Office Healthcare Fraud Squad.
FierceHealthPayer:Anti-Fraud: How can special investigations units improve their working relationships with law enforcement?
Tips: Maximize face-to-face interaction. Treat law enforcement as corporate customers.
Ralph Carpenter: There's no better way to develop a relationship than face-to-face contacts. Commit to engaging with law enforcement, whether it's at the state, local or federal level. A number of law enforcement agencies have task force or informational meetings. Have your investigators or analysts participate in as many of those as possible. Then if you're having an issue with a provider or member and need law enforcement assistance, they'll know and remember you. It becomes easier to work collaboratively and cooperatively.
Also, network at annual NHCAA training meetings, where a significant number of law enforcement and private payers are present. Take advantage of training sessions law enforcement offers on topics, such as interviewing techniques and developing evidence packages. Make law enforcement part of your customer relations strategy because they're stakeholders.
Christine O'Neill: Consider having quarterly working group meetings with law enforcement. My agents and I have one-on-one working relationships with SIU investigators, so if either of us have questions, we know who to contact. Sometimes it's difficult for insurers to share information in a large setting, so we have smaller meetings with larger insurers where they can share information on particular fraud schemes. This helps us identify issues that rise to the federal level that we should be pursuing.
FHPAF: How can insurers improve the quality of their case referrals to law enforcement?
Tips: Document thoroughly. Interview perceptively. Make specialists available for follow-up questions.
Carpenter: Assemble timely and accurate evidence packages. Use due diligence in putting data together so law enforcement gets a package that's clear and cogent. Make qualified staff (for example, medical professionals) available to answer specialized questions law enforcement may have about cases.
O'Neill: Document, document, document! Get as many details as possible in your investigations. Often when law enforcement questions individuals, they're not as apt to share details; but if an SIU investigator questions them, it's not as threatening.
Sometimes SIUs can get details that would take law enforcement several interviews to extract. Be conscientious about documenting what you see and hear. For example, if you're visiting a facility and don't see particular equipment there and then find out a facility provider is billing for procedures requiring such equipment, document that so law enforcement has a good investigative starting point.
FHPAF: Is there an optimal time for SIUs to get law enforcement involved in a fraud case? If so, when should this be done?
Tips: Find the golden mean on case referral timing. Consult law enforcement before acting against potential fraudsters.
Carpenter: Follow the requirements and guidelines set by state and federal agencies. But make a connection with law enforcement as soon as possible when you've developed an issue that's worthy of forwarding, because the sooner we engage, the more success we have. But don't send over false positives, where you haven't done enough due diligence to ensure that the case at least has the potential to merit law enforcement review.
Find a middle ground on case referral timing. The last thing you want to do is put together a whole evidence package you've been working on for a year and dump it on somebody's desk. If you consulted law enforcement earlier in a case like this, they would have offered counsel about what they'd need to shore up the case if they were to take it on.
O'Neill: Consult law enforcement prior to taking action against the potential fraudster by, for example stopping provider payments. Premature action might change the way that individual does business or how they perpetrate their fraud. If insurers come to law enforcement before taking action against the fraudster, we can work in concert, develop a much better case and advance the case faster.
FHPAF: Is there anything SIUs can do in their work processes to increase the likelihood of successful prosecutions in major fraud cases?
Tips: Add law enforcement outreach to workflows. Identify and refer clear fraud issues.
Carpenter: Make staying connected with prosecuting and investigating authorities part of your workflow to maximize opportunities for success.
O'Neill: Remember cases that are most successfully prosecuted federally involve blatant fraud: Billing for services not rendered, billing by individuals who aren't certified to provide those services. Unless it's a question of patient safety or patient harm, we do not want to get into a battle of medical necessity. If the sole basis of a case is interpretation of medical necessity, then that's not as easy of a sell to a U.S. Attorney's Office.
And while one small insurer's loss amount may not rise to the level of federal prosecution, if we start to hearing the same theme from multiple insurers, we know we've got a problem that needs to be addressed, and it's something that would rise to the level of us getting involved.