On a recent trip to South Florida, I came across some very interesting sights that gave me pause. The first was the combination of an Adult Day Care/Auto Garage, as pictured. The second was a similar combo of Home Health Care in the same storefront as a Guns/Ammo distributor (sorry, didn’t get a photo of that one). While there may be legitimate reasons for the juxtaposition of these businesses, as an investigator, seeing these entities should make you want to ask questions.

While finding them on a road trip may be happenstance, these same types of “what the heck?” scenarios can be found every day in the data we are all mining. Sometimes, the fraud is hiding in plain sight, but we need to step back from the complex data models we are used to using to actually see it.

Finding the not-so-subtle schemes (static billing, patterns of claims after dates of death, using dead providers’ NPIs) can be difficult if we are focusing on the deeper, more complex data anomalies. So, keep your eyes open for the simpler ones too.

And when you find them – don’t think you have them in the bag. There may be explanations for even the most outrageous circumstances. For example, in the photo I shared, it looks like there is an adult day care facility being run out of an auto garage. However, on closer inspection (after a right turn), what was found was a separate building hidden to the left of the garage where the day care center was actually housed. They were just using the side of the garage to advertise to the cross traffic. Still, it was worth further review.

Final Thoughts

As fraud hunters, our mission is to track down the elusive prey hiding within complex data sets. But we must remember that not all fraud hides in the brush; some of it presents itself in plain sight. It’s essential to look beyond the data and be ready to question the unexpected.

During our investigations, we may stumble upon things that simply don’t make sense at first glance. Couples receiving identical services on the same day, or multiple durable medical equipment (DME) suppliers opening shop on the same block – these anomalies should raise our eyebrows.

The key is to search for the unexplainable and attempt to find rational explanations. Perhaps there are legitimate reasons for such occurrences, but if our efforts to uncover the truth come up empty, we might be onto something significant.

So, let’s keep our eyes open and maintain a curious mindset. Combining data analysis with critical thinking will lead us to discover both the commonplace and the extraordinary. In our hunt for fraud, every piece of the puzzle matters – no matter how peculiar it may seem at first.

Happy hunting!

By Matt Kochanski