Every investigator knows that keeping your focus on the allegation is the key to efficiently conducting your investigation. There are times, however, when keeping those blinders on will result in the investigator not seeing the bigger picture. While investigating what is in front of you is important, it is also an important aspect of the job to ascertain whether the picture in front of you is just a part of a larger mural that surrounds you.
In certain cases – that involve issues in known “hotbeds” or where the patterns seem similar to other cases in your current or closed inventory – it may be beneficial to look beyond the allegation to see if there are connections to a larger scheme.
The data can show you if there are referrals to/from known suspect providers. Looking at beneficiary histories may show some connections, as will researching the billing company, management officials, owners or registered agents listed on enrollment documents or Secretary of State records.
Link analysis software can help make these connections and allow you to create visualizations of them. These tools can help in your investigative planning. Some avenues that have been used in the past included “following the beneficiaries,” looking to see if providers were moving from provider group to provider group, looking for common referring physicians, etc.
Of course, the more linkages made, the more complex the case. So, you have to remember, even in connecting multiple providers, entities, billing companies, etc., you need to investigate each one to see if they are individually doing anything wrong (some illicit behavior like kickbacks will involve multiple parties) but false billing is done on an individual basis (even if it is orchestrated with others) so it must be investigated on its own merits.
Bottom line – Think broadly but continue to focus.
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