The Fraud Examiner
Hiding in Plain Sight
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
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