When people discuss the various ways in which healthcare programs are exploited, they often use the umbrella term “Fraud, Waste, and Abuse.” These terms have been employed interchangeably for many years, but the spectrum of behaviors they encompass is wide. It is crucial for investigators to pinpoint where their subject’s behavior falls within this continuum. This determination profoundly influences how an investigation is conducted, including the steps to be taken and the evidence to be gathered. Furthermore, it shapes the appropriate remedy for the behavior, whether it involves overpayment recovery, education, licensing referrals, or even law enforcement involvement.
But how can one make such a determination? The key factor, particularly when assessing the potential for genuine fraud, is whether there is evidence that the healthcare provider had the “intent” to deceive the program(s) to gain benefits they were not entitled to receive. Essentially, investigators must ascertain if there is proof that these providers knowingly engaged in deceptive practices, fully aware that it was illegal.
While data analytics and medical reviews can provide valuable leads and guide investigators, identifying “intent” and the potential for fraud necessitates getting into the mindset of the provider. There is only one way to achieve this: through interviews. Data, open-source research, document reviews, and medical assessments can point investigators toward individuals who need to be interviewed, but it is only through these interviews that “intent” can be established.
Superbills may reveal the internal billing process, but speaking with the Office Manager or Billing Clerk is the only way to understand the provider’s instructions regarding billing, any discussions or concerns raised about the propriety of these instructions, and how the provider reacted to such inquiries.
Likewise, medical records can indicate irregularities like cloned records, but interacting with office staff is the sole means of uncovering how this occurred and who was responsible.
Another approach investigators can adopt is to think like the provider by asking themselves why the provider engaged in the observed behaviors. What motivates the billing patterns? To ensure that the investigation stays on the right track, investigators must consider all possibilities, both those that support the theory of malicious intent and those that provide legitimate explanations. Each possibility must be thoroughly explored. A strong case is one where legitimate reasons for the behavior were considered and investigated but ultimately proved inadequate, leaving bad intent as the only plausible explanation. Investigators must avoid automatically assuming bad faith on the part of the provider, as this can lead to dead ends or, in the worst-case scenario, an embarrassing defeat at trial. Investigating the potential for legitimate reasons behind seemingly suspicious patterns is just as much a success as a well-packaged referral to law enforcement.
The final question is: Whose responsibility is it to determine intent? Is it the SIU Investigator or the law enforcement agency to which the referral is made? The answer lies in the relationships established among these entities. Each law enforcement agency has different expectations that must be understood and followed. Some prefer a comprehensive package with all the details neatly tied together, while others discourage SIU Investigators from communicating with anyone associated with the provider. Adhering to these expectations is essential for SIU success in this arena.