Fraud investigation tips from Deloitte's Mike Little

Part 1 of an exclusive interview with FierceHealthPayer: Anti-Fraud
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FierceHealthPayer: Anti-Fraud:  You wrote that "interviews may be the most important part of a forensic investigation." Why is that, and how can SIUs improve the effectiveness of their interviewing?

Mike Little: Until you ask questions, you won't know why and how an event occurred. So interview the referral source (if there was one) and then seek out individuals in a position to know what happened. Was it an accident? Was it reckless? Was it part of a pattern? And most importantly, was it intentional?

Records are vital, but they can be lifeless and deceiving. After all, the key to committing a successful fraud is to make everything look legitimate.

Here's an example of the role interviews can play in explaining and dissecting documents that look legitimate but aren't: I investigated an ambulance company whose records showed if a Medicare-approved service was provided. This involved the equipment dispatched.

An inside source told us the company's owner was concerned about being audited. So he told employees how to fill out the forms. There were two boxes on them. One showed that Medicare-approved equipment was used, the other showed use of nonapproved equipment.

The owner told employees that if they didn't need to use approved equipment--if they could get away with using a van instead of an ambulance, for example--they should put an "x" in the place where the form said "ambulance." But if they dispatched an ambulance, they should put a check mark in that box.

Just by looking at the forms, you wouldn't know what the X's and check marks meant.

The thousands of documents we obtained from a search warrant as a result of this information coupled with insider testimony provided powerful evidence of fraud. This resulted in criminal prosecution and a jail sentence for the owner.

Remember that interviews can identify new areas of investigative interest. Always end an interview by asking, "Is there anything we didn't ask you that you think could be significant?"

It's a productive question. One person answered it by saying "Would you like to hear about all the doctors' names we forged on Medicaid forms?" That wasn't a focus of our investigation until then.

Interviewing isn't something people instinctively know. It's a teachable skill requiring experience and practice.

Preparation is key: Know as much as you can about the subject before doing an interview. Focus on what has been learned to date and what you need to learn from an interviewee. Know what documents you want to show them or have them review for you.

Besides getting formal interview training for SIU staff, it's valuable to send out less experienced employees with skilled interviewers to see how it's done and learn on the job.

Editor's Note: This interview segment has been edited and condensed for clarity. Look for part 2 of the interview with Little next week.

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