The Fraud Examiner

Hiding in Plain Sight
 

November 2013 

By Diane Burley 

  

Fraud and falsehood only dread examination. Truth invites it.
– Samuel Johnson
 

  

The illusionist’s slight of hand amuses and confounds us. It is right before our eyes -- but yet we can’t see it! In fact, illusionists are masters at manipulating our attention – of having us focus intently away from where the trick is being played out.  Skilled perpetrators of fraud do essentially the same thing. They know instinctively, if not cognitively, that the human brain is wired so that as it focus on one set of information – it must shut out other information.  

  

That’s why it was so easy for Cliff U., his wife Ezinne, their partners, Princewill N. and his wife Caroline, to steal more than $5 million through healthcare fraud. The two men had founded a Houston-based home health care company that said it provided skilled nursing to Medicare beneficiaries. Caroline and her staff were responsible for recruiting Medicare patients, while Ezinne was a registered nurse who, with her staff, wrote care plans for home-bound patients.   

  

On the surface, it all looked legitimate. And indeed, there are many such legitimate operations just like these all over the country. But in fact, the healthcare group’s patients were not homebound, nor did they need (or receive) skilled nursing services. Yet they billed CMS (Centers for Medicare and Medicaid Services) and received payment for those non-services.  

  

Finding the Cliffs and Ezinnes of the world has been near impossible for forensic accountants and investigators, because their actions, albeit criminal, look so reasonable -- which is how, according to the FBI, CMS alone is bilked of $80 billion each year. Forensic accountants are trained to look for anomalies: Is a bill excessively high? Is the same amount being processed over and over and over again? Are the number of patients for a single practitioner realistic?  


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