Medicaid fraud is a massive problem in the United States. One estimate is that Medicare and Medicaid fraud costs taxpayers more than $100 billion a year, and another organization has estimated that Medicaid’s improper payments ran to $161 billion between 2008 and 2016. Most of the fraud is committed by providers, and typical schemes include billing for services not provided or visits that didn’t occur, ordering unnecessary tests, or listing services under improper codes that result in higher reimbursements. Almost every state plus the District of Columbia has a Medicaid Fraud Control Units (MFCUs) to investigate and prosecute Medicaid fraud, and as with so many other law enforcement agencies, MFCUs tend to be understaffed and overworked. MFCUs often seek Medicaid fraud software because they face a particular set of challenges:
- Investigating Medicaid fraud is a complex and multipronged effort that requires collecting evidence, uncovering networks, tracking down collaborators, and more. Without the ability to search for this information quickly and accurately, investigators won’t be able to keep up with the high volume of investigations, and clearance rates will suffer.
- Overworked agencies across the country seeking Medicaid fraud software need to easily prioritize and track assignments, store ongoing case information, and submit cases for prosecution — preferably all within the same system. Too many agencies today are working in siloes and toggling between multiple applications to manage their investigative efforts, stalling progress.
- Investigators managing a massive Medicaid fraud caseload will ideally take the leads they’ve quickly and accurately identified (as discussed in the first bullet point) and import these leads into a comprehensive case management system (as discussed in the second bullet point). These two components ultimately complement one another, and without that readily available integration, overall investigative efficiency will suffer, making it more likely that fraud cases will go uninvestigated, unsolved, or unprosecuted.
- Investigations of individual cases often reveal larger criminal trends and networks, particularly when they involve issues like phantom billing, upcoding, ping-ponging, unbundling, etc. A lack of analytic tools during this discovery process can prevent investigators from seeing the bigger picture, potentially stalling investigative progress.
Looking to leverage advanced technology to make your MFCU more efficient and more effective? Reach out to our sales team to see if CaseBuilder and CrimeTracer make sense for your agency.
CrimeTracer and CaseBuilder
SoundThinking’s investigation management solutions, particularly the law enforcement search engine CrimeTracer and the case management software CaseBuilder, are the kind of force multipliers MFCUs need to be able to do more with less and successfully carry out investigations. In this article, we will discuss how both technologies help facilitate a robust Medicaid fraud investigation.
Key Feature #1: CrimeTracer’s Search Capabilities Uncover Qualified Leads and Expedites Investigations
Understaffed and overworked agencies investigating Medicaid fraud and seeking effective Medicaid fraud software need to be able to efficiently analyze data, as well as quickly search for any other information that may be relevant to the investigation. Without that ability, investigators will dedicate excessive amounts of time sifting through documentation attempting to uncover connections between different people, locations, causes, and criminal enterprises, with mixed results. Even today, many MFCUs rely primarily on RMS systems for their data sources, systems built for initial reporting but not investigative follow-up.
CrimeTracer, by contrast, makes it fast and easy to search and analyze data. With the tool’s Quick Search feature, investigators can comb through both structured and unstructured data in reports for names, addresses, and other data and generate a dashboard showing links among them.
This has several useful applications for agencies investigating Medicaid fraud. For example, one telltale sign of fraud that investigators look for is outliers among billing practices. Let’s say there’s one practitioner who is billing for a particularly high-reimbursement Current Procedural Terminology (CPT) code at an unusual frequency, or another provider claiming to see an implausible number of patients in a day. By searching the practitioners’ names and finding associated addresses, investigators could identify providers (or patients) who seemed to be living beyond their means. Matching that information with apparently excessive billing would be a good sign of something to investigate further.
Although, with that said, it’s also important to recognize that Medicaid fraud is not always the work of serial offenders. Some perpetrators are first-time offenders, some perpetrators are provider groups or networks, and some providers may be serial offenders who have concealed their fraudulent activities behind numerous shell companies, and they may not turn up in criminal records. However, these groups of shell companies might all share a phone number or associated banking account, and searching for this information based on a tip could point to the web of shell companies at work.
CrimeTracer’s visualizer toolbar makes it easy to track connections between multiple providers and potential associates.
CrimeTracer lets you not only uncover outliers but also leverage link analysis to build out a picture of their connections—patients, other providers those patients might see, labs or treatment centers they often refer patients to, and so on.
Key Feature #2: CaseBuilder’s Searchable Index Brings Order to Chaos
As we mentioned earlier, overworked agencies across the country navigating Medicaid fraud prevention need to easily prioritize and track assignments, store ongoing case information, and submit cases for prosecution — preferably all within the same system. Too many agencies today are working in siloes and toggling between multiple applications to manage their investigative efforts, stalling investigative progress.
With CaseBuilder’s digital case folders, investigators focused on Medicaid fraud prevention can collect the data, observations, tips, notes, and other material to create a single source of truth. It also organizes the data with a searchable, chronological index to let investigators easily view the status of an investigation. For prioritizing the next steps, agencies can create their own checklists of actions and procedures, to ensure consistency and adherence to standards.
Once a case is ready to turn over for prosecution, CaseBuilder’s “Disseminate Case” button enables investigators to automatically route casework through approval processes and develop interactive presentations for court via the case folder dashboard.
Key Feature # 3: One-Click Information Sharing Between CrimeTracer and CaseBuilder Supports Every Component of a Robust Investigation
The two components of the SoundThinking solution already discussed, CrimeTracer and CaseBuilder, can be used autonomously but are also integrated in ways that support every component of a robust Medicaid fraud investigation. Let’s look at how this integration works.
Say you have limited background information about a medical provider you suspect is engaging in fraud, perhaps based on a tip. You’ve entered that information into your digital case folder in CaseBuilder. Now, starting with that name, it takes only one click to instigate a search for that person in CrimeTracer. Two things can happen at that point:
- You get an exact hit—that person’s name is already in one of the databases CrimeTracer can search. When you click on the name, the search engine provides more details, such as demographics. With one click, you can attach all that information to the person’s name in your CaseBuilder folder.
- You also start leveraging CrimeTracer’s ability to uncover connections between people, so you start pulling on that string of visual links, such as connected associates, known patients, etc. As with the original subject, you can quickly click and add those new connections back into CaseBuilder, along with all their associated information, as leads you can follow up on.
Conduct investigative follow-ups and identify associated links in CrimeTracer and then import them into CaseBuilder
While CaseBuilder and CrimeTracer are designed to work well autonomously, the two applications work together seamlessly to expedite investigations.
Key Feature # 4: CrimeTracer’s Link Analysis Tool and CaseBuilder’s Criminal Enterprise Dashboard Help Investigators Piece Together Larger Trends
Some Medicaid fraud cases involve multiple participants, and in these scenarios, it’s critically important for investigators to quickly detect relationships between people, places, and events.
With the link analysis functionality in CaseBuilder and CrimeTracer, investigators can identify connections and quickly detect relationships between people, places, and events. With this functionality, investigators are better able to identify troublesome trends and/or changes in purchasing habits that could indicate coordinated, fraudulent activity.
CaseBuilder’s Criminal Enterprise Management Platform: Targeting Enterprises that are Large, Complex, and Highly Organized
Furthermore, our contacts and research have shown that businesses and individuals operate organized criminal organizations to exploit the massive amount of funding that is available. With CaseBuilder’s Criminal Enterprise Management dashboard, investigators can keep close track of a criminal enterprise by meticulously documenting activities, as well as noting any members who have been arrested, and intelligence work that makes note of activities or associations that may lead to other members in an organization, ultimately expediting investigations.
Example Criminal Enterprise Dashboard
A Checklist for Assessing the Best Medicaid Fraud Investigation Platform
- Does it make it quick and easy to search for people and uncover anomalies and relationships?
- Does it organize collected information into a single searchable source of truth that can be used to manage and prioritize an investigation?
- Is it possible to easily initiate a search on information that’s in the case folder and import the results back into the folder?
- Does it support uncovering the bigger picture and identifying overall trends that can help reduce fraud?
Conclusion
Investigation management software is a critical part of the toolbox for investigators focused on Medicaid fraud prevention. The ability to search reports and records to uncover anomalies and connections, determine linkages between suspects’ networks, manage and track the status of an investigation, and more will ultimately make MFCUs more efficient and effective and reduce fraud.
