The biggest mistake a healthcare investigator can make is to forget what their mission is. It is not to solve a crime; it is to follow the facts to determine if a crime has been committed. Healthcare fraud investigative work is the opposite of detective work. A detective tries to find clues to point them in the direction of who committed a known crime. A healthcare investigator looks for facts to try to determine if the pattern of behavior they are investigating is a crime. The detective is solving a “whodunit” – a crime has been committed, and they need to find out who did it. The healthcare investigator knows who did it; they are trying to discover if what was done is wrong or not.

And it is the facts that will get you there. What were the policies and regulations in place? What was billed? Were they in line with the policies? Were there legitimate reasons why the billing looked suspect but was actually correct? Let the trail of facts lead you to the conclusion. If the facts uncover nothing wrong, close the case and consider it a job well done. If the facts lead to a discovery of wrongdoing, then take the next steps to pursue that. And consider that a job equally well done.

An investigator should be equally satisfied with either outcome if the outcomes were based on solid, efficient fact-finding.

Final thoughts:

  • Investigators search for facts
  • Investigators must follow where the facts take them.
  • No matter where the trail leads, the goal is the same – find out what happened
  • Reaching that goal should be rewarding – whether the facts lead to finding fraud, waste or abuse or lead to a finding that there is nothing wrong.
  • So, if facts are leading you one way; don’t take detours to change the outcome.

Happy hunting!

By Matt Kochanski