Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Organized Crime

Organized crime entities are the ultimate winners in this game. They have the luxury of having no regard for laws, compliance programs, reporting or requirements, quality controls, or patient safety standards. What matters to this group are activities like getting illegitimate access to PHI, stealing inventory, and reintroducing inventory that has been stolen, counterfeited, or adulterated. Laws have no impact on this group. The intent is to steal. The list of fraudulent activities can go on and on, as can statements like these:

“I have a great idea for a quick high-profit scheme.”

“It will require these types of resources, people, and systems.”

“We can split the profits in the following manner.”

“We do the following activities to avoid detection.”

“Let’s hire patient care technicians to provide evaluation management services—that way we can give Medicare the bell-shaped curve that Medicare wants to see.”

Fraudsters never include in their plans, “We should get caught and prosecuted.” Fraudsters do not go into high-risk, illegal businesses to get caught, but to reap high monetary rewards.

Sample Organized Crime Fraud Scenarios

Perpetrator Examples

• A Russian resident hired runners in the United States to run P.O. boxes set up to receive checks for false claims submissions. His specialty was collecting the Social Security numbers of deceased Russian immigrants. He did not even have to travel to the United States to steal from its government programs.
• Outpatient ...