In an upcoming webinar, we look at the rising instances of government healthcare fraud and how technology is enabling the criminals
Organized criminal syndicates committed massive fraud throughout the pandemic. Moreover, 40% of respondents to the said they believe that the prevalence of government fraud, waste, and abuse would increase in 2021, whereas more than half (53%) felt things would stay the same. While there is still more work to be done to fight fraud, the battle just got a little trickier.
Fraud networks have typically been based out of known global fraud hotspots, such as and Eastern Europe. Now however, with the rise of technology tools, we are seeing a diverse set of bad actors from multiple countries looking to commit healthcare fraud schemes.
鈥淲e are seeing diversification. Fraud is coming from all over the place,鈥� says Amanda D鈥橝mico, Senior Director of Fraud, Risk, & Compliance at 成人VR视频鈥� Pondera. 鈥淚n one particular instance, we had a client with suspicious claims tied to IP addresses from 150 distinct countries.鈥�
These criminal groups are sophisticated, pre-planning their fraud activity to hit the next big thing. While the Payroll Protection Program (PPP) was but one example of a massive windfall for fraudsters who wanted quick cash, they already are moving on to the next level of fraud. And that is where government healthcare programs come into play.
It requires a little more patience by the bad guys, D鈥橝mico says, adding that this is where the growth is happening. Further, technology is helping enable these groups. In some instances, it will be bots that are filing fake medical claims in bulk, manned by teams of fraudsters in foreign countries also making phony claims.
Some fraudsters work in a criminal conspiracy with healthcare providers, while others do not. In fact, healthcare fraud schemes can be simple or complex and can be committed by a variety of persons including medical providers, patients, and others who intentionally deceive the healthcare system to receive unlawful benefits or payments.
Tracking the fraud
, financial crimes expert and bestselling author of 30 books, says that financial authorities shouldn鈥檛 get overly concerned that cryptocurrencies and digital payment services are making it easier to move money across the world. 鈥淔raud is fraud,鈥� Robinson explains. 鈥淲hen it comes to fraud, forget the money and don鈥檛 worry about how it moves. There is nothing new here. Concentrate on this: That fraud is a very simple crime to understand. I tell you a lie, you give me money, that’s fraud. The money doesn鈥檛 matter and how it moves doesn鈥檛 matter because fraud is never any more complicated than that.”
Among the primary victims of healthcare fraud rings are members of more such as new immigrants to the U.S. or undocumented workers with limited English proficiency, as well as the elderly and the developmentally disabled. These are individuals who most depend on government programs like Medicaid and Medicare, says D鈥橝mico.
Like unemployment insurance fraud, criminals need a certain amount of personal identifying information to bill for a service. Data breaches have been a primary source of such information, but another growing concern is disguising themselves as relief or free-or low-cost legal providers. Sometimes they set up websites that look like U.S. government relief sites, but are not.
鈥淐riminals set up fake organizations to 鈥榟elp鈥� people through the citizenship process or to obtain a driver鈥檚 license or an identification card, claiming it will help the victim get access to food, cash benefits, and Medicaid assistance,鈥� says D鈥橝mico. In that process, the criminals obtain key data elements and use those to fraudulently apply for benefits on the victim鈥檚 behalf. With benefits programs overwhelmed by the volume of claims, it is often easier for fraud claims to blend in with legitimate claim filings.
Technology is a force multiplier
Healthcare fraud schemes involving criminal networks aren鈥檛 new, D鈥橝mico says, adding that such illicit networks have had their tentacles into these programs for a long time. Now, they are going to use the further opportunity presented by the COVID-19 pandemic 鈥� and the government programs created to relieve this crisis 鈥� to expand their nefarious activities. 鈥淭echnology is a great enabler,鈥� she says. 鈥淚t is the tool that facilitates rapid onboarding of a new scheme. We will see claims for services or treatments that were never performed, but because of technology, it will happen at scale.鈥� Indeed, several sophisticated programs have been built for fraudsters to use in a systematic way.
D鈥橝mico鈥檚 advice to fight medical fraud is:
Recognize risk 鈥� Recognize evolving risk and how it presents itself in a healthcare setting. The prevention techniques that might have worked in 2019, may not work in 2021 and beyond.
Be nimble 鈥� Be ready to adjust your prevention strategies to keep pace with the bad actors and understand where your vulnerabilities are. Is it an extra cybersecurity measure you need to take? Or something else?
Perform enhanced due diligence 鈥� Consider leveraging technology programs to help run enhanced due diligence checks on potentially fraudulent claims, especially when they come in bulk. Run a background checks not only on providers, if those are present, but on other entities that may be connected to them. Often, criminal organizations use a 鈥渇rontman鈥� with a clean criminal history to do the work.
To learn more about global healthcare fraud schemes and how to prevent them, join us September 13-15 at the . Amanda D鈥橝mico will be in conversation with Jeffrey Robinson during our panel, .
