Identity Resolution Daily

[Post from Infoglide] New Record for Healthcare Fraud: $163 Million

“Last night the largest Medicare fraud operation yet discovered was in the headlines: ‘A vast network of Armenian gangsters and their associates used phantom health care clinics and other means to try to cheat Medicare out of $163 million, the largest fraud by one criminal enterprise in the program’s history, U.S. authorities said Wednesday. Federal prosecutors in New York and elsewhere charged 73 people.’”

Government Executive: Most domestic intel centers lack privacy plans

“After the Sept. 11, 2001, terrorist attacks, the U.S. government encouraged and funded a proliferation of domestic counterterrorism centers, commonly referred to as state and local homeland security fusion centers. Although 72 centers now exist, only 28 have privacy and civil liberties plans approved by the Homeland Security Department, National Journal has learned.”

marketwire: Cloud Computing Market to Reach $25 Billion by 2013

“Worldwide Cloud Computing market is continuing to grow at a rapid rate and it is expected to cross US$ 25 Billion by the end of 2013. The different segments of the Cloud Computing market (SaaS, PaaS, IaaS) show different maturities and adoption levels. The various segments within the SaaS market will grow at a different rate.”

TravelAgentCentral: Update: Secure Flight Rules Effective November 1

“Secure Flight watch list matching takes a matter of seconds to complete, and providing this data enables passengers to print their boarding passes at home or at an airline kiosk, TSA notes. The November 1 deadline marks the end of the year-long grace period for airlines to clear out their systems of older reservations made before Secure Flight requirements took effect in October 2009. After November 1, 2010, Secure Flight will not conduct watch list matching or approve the issuance of a boarding pass by an airline if complete passenger data is not submitted, the TSA says.”

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By Mike Betron, Infoglide Software Director of Marketing

Last night the largest Medicare fraud operation yet discovered was in the headlines:

A vast network of Armenian gangsters and their associates used phantom health care clinics and other means to try to cheat Medicare out of $163 million, the largest fraud by one criminal enterprise in the program’s history, U.S. authorities said Wednesday. Federal prosecutors in New York and elsewhere charged 73 people. Most of the defendants were captured during raids Wednesday morning in New York City and Los Angeles, but there also were arrests in New Mexico, Georgia and Ohio.

The latest installment in this ongoing saga includes billing for unnecessary and never performed procedures, stolen identities, and phony clinics:

The defendants in the New York case also had stolen the identities of doctors and set up 118 phantom clinics in 25 states, authorities said. The names were used to submit fake bills for care that was never given, they said.

How can those responsible for payments not detect phony clinics? Many sources of public and private information are available to validate their existence, yet apparently systems to perform this function are not in place 45 years after Medicare was created. As Mike Shultz said here in a June post:

Honest suppliers stand by helplessly as competitors cash in on the bonanza. One such supplier wrote in a guest post about how current detection methods are inadequate and how the problem can be attacked with the right technology.

Several months ago I asked the question, that if “every day, identity resolution software screens every airline passenger on every U.S. domestic flight to prevent known criminals and terrorists from boarding airplanes without being detected,” then “could the same technology be used to make the whole Medicare and Medicaid infrastructure more proactive in preventing fraud?” The answer is still “yes.”

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By the Infoglide Team

Kaiser Health News: Medical Loss Ratio Rule Should Encourage Health Care Fraud Fighting

“There is undoubtedly a direct connection between health care fraud and health care quality. Consider the Kansas physician convicted of health care fraud linked to the death of patient. He had been running a ‘pill mill’ in a small town, which led to more than 100 overdoses and at least 68 deaths. All the while, he submitted millions of dollars in false claims to government programs and private insurers.”

Miami Herald: Final phase of TSA’s Secure Flight program taking effect

“The information will be required on third-party online booking sites and with travel agents as well as directly through the airlines, according to TSA. David Castelveter, spokesman for the Air Transport Association, said airlines have updated their reservation systems as needed since TSA started requiring airlines to collect the data a year ago. He said compliance on the part of passengers is necessary for their ease of travel.”

Washington Independent: Combatting Homegrown Terrorism With Fusion Centers

“One of the ways DHS is approaching this threat is by beefing up the country’s network of fusion centers — groups that fuse local law enforcement work with national-level intelligence.”

backupify: The Economics of Cloud Computing

“Cloud computing became the hot topic of discussion when the recession hit and companies had to tighen up their budgets. They could no longer afford expensive servers, clunky software, and entire IT teams to manage this infrastructure. Cost constraints led decision makers to open their minds to cloud computing. At this time, cloud computing was a fairly new concept and term, which led to many raised eyebrows and question marks. However, as companies slowly adopted cloud services, many others began to understand its purpose and benefits.”

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[Post from Infoglide] Commercial Fusion Centers

“Several years ago, the Department of Homeland Security (DHS) published guidelines for creating fusion centers at the state, local, and federal levels. Since then, fusion centers have become a hot trend in the law enforcement community… If governmental agencies with common concerns can band together to create fusion centers, it seems possible that private companies with common goals could use technologies such as identity resolution to achieve them.”

Wisconsin Radio Network: Compliance check nets lottery liars

“According to a release (PDF)  from the office of Attorney General J.B. Van Hollen, 36 year-old Tyna Dull of Arena was charged in Iowa County Circuit Court, and 28 year-old Travis Ferguson of Gotham was charged in Richland County Circuit Court, each with one count each of Attempted Theft By Fraud. Dull and Fergison told Special Agent from the state Division of Criminal Investigation that the Lottery tickets presented by the agents as part of a Lottery compliance check, were not winning tickets.”

DBJ: Healthcare Quarterly: Hospitals’ road to EMRs costly

“Texas Health started installing its electronic medical records system four years ago and expects to spend more than $200 million by 2012 in capital and operating expenses to put the system in place, said Edward Marx, chief information officer. The hospital system expects to receive about $70 million in federal stimulus money over five years, beginning in early 2011, Velasco said. Patients are already experiencing the benefits of digitized records in Texas Health Resources hospitals, because the records are accessible to the appropriate care-giving team regardless of where the patient is moved in the hospital, Velasco said.”

NBCDFW: New Security Check Could Delay Air Travelers

 ”The program, called ‘Secure Flight,’ was first implemented in August 2009. The government has given airlines more than a year to comply. The names will be checked with a federal database of terrorism suspects. The TSA says the added information will prevent many passengers from being misidentified as a potential terrorist. ‘Worst case scenario, if the person doesn’t have this information, they’ll be redirected back to the ticket counter to provide the information so they can get the boarding pass,’ TSA spokesman Luis Casanova said.”

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[Post from Infoglide] Preventable Nightmares?

“Every father’s nightmare happened in North Carolina this week. A young woman apparently left a bar voluntarily with a man she met there, and she was subsequently found murdered. The apparent murderer arrested in Niagara Falls had a criminal record that included sexual abuse and was on probation in North Carolina. Could this tragedy have been prevented?”

mydesert.com: Palm Desert store the good guys in lottery fraud investigation

“In the sting, investigators presented lottery retailers with winning lottery tickets for large dollar amounts and tested whether the retailer would properly inform them of their winnings. The Jensen’s on Cook Street was the only retailer who informed the undercover agent of his winnings.”

Fort Worth Star-Telegram: Airline passengers to face new security rules

“American spokesman Billy Sanez said that for tickets purchased before Sept. 15 for travel dates Nov. 1 and later, the Secure Flight data was requested but not required. The airline’s reservation system now requires the data for travel after Nov. 1. ‘Now, you won’t be able to get a ticket if you don’t give us that information,’ Sanez said. He said it must be provided no matter where the ticket is purchased: online, through a travel agency or at the airport.”

DOJ: Lowell Couple Pleads Guilty in Under-the-Table Payroll Scheme

“The defendants concealed the true size of their payroll from the IRS, and from their workers compensation insurer, in order to reduce their employer payroll taxes (FICA) and their workers compensation insurance payments. They did this by paying their employees in cash each week and hiding any record of the payments. Even though they retained a payroll service, they routinely told the service that C&A had no work and therefore no employees. Relying on this misrepresentation, the payroll service filed over 20 quarterly payroll tax returns on behalf of C&A that reported no payroll.”

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[Post from Infoglide] Making Systems Smarter

“Several years ago, identity resolution  was almost exclusively tied to detecting fraud. Over time, the ‘identity’ of identity resolution has continued to evolve and broaden. Many areas of commerce are discovering that efficiency can be improved dramatically when you have a clear picture of the individuals you’re dealing with and their social network. Of course, identity resolution is not the only way to gain that efficiency.”

Workers’ Compensation: Facebook Makes an Appearance in Workers’ Compensation Court

“In a recently published article, Law School Professor Gregory M. Duhl and attorney Jaclyn S. Millner, focus on the issues of professional responsibility, discovery, privacy and evidence when social networking factors integrate with a workers’s compensation proceeding. Since the compensation system is theoretically no-fault and the evidentiary system is informal, the authors theorize that the workers’ compensation arena will act as a fertile ground for experimentation in the legal application of this new technology.”

MassDevice: Clinical Science coughs up $525,000 to settle Medicaid fraud allegations

“‘We will continue to work with our state and federal partners to police abuse of the program that so many people depend on,’ Coakley said in prepared remarks. Over the last three years, Coakley’s Medicaid fraud division has recovered approximately $125 million for the state Medicaid program, according to the AG’s office.”

The 33: TSA demands more information from air travelers

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[Post from Infoglide] International Privacy Compliance

“International companies, particularly those in the financial services markets, have long struggled to comply with the varying data privacy laws of the countries in which they operate.  Simple data analysis practices in one region of the world may or may not be acceptable in another, and the penalties of non-compliance can be harsh to say the least.  This leads to inefficiencies in areas such as AML, Compliance and Fraud Investigation.”

nj.com: Elizabeth doctor is charged with hiring phony physicians to bilk Medicaid

“Despite their alleged lack of medical licenses, authorities say, the trio treated thousands of disabled and low-income patients, helping Masood bilk at least $1.8 million from Medicaid, the federally funded health care program for the poor. ‘Unsuspecting patients were placed at risk through deceit and substandard medical care, while taxpayers were being defrauded of millions of dollars,’ said Michael B. Ward, head of the FBI’s Newark office.”

FierceGovernmentIT: More DHS components to receive Watchlist Service data from FBI

“The specific initial recipients of the new automated service were identified as the TSA’s Office of Transportation Threat Assessment and Credentialing; the TSA Secure Flight Program; CBP’s Passenger Systems Program Office for inclusion in the Traveler Enforcement Compliance System; and US-VISIT for inclusion into the DHS Automated Biometric Identification System (IDENT).”

East Valley Tribune: Authorities: Valleywide crime database nears reality

“‘There are so many databases out there, officers want to be able to get into one portal for information,” Romley said. “Technology capabilities have improved immensely over the years, the real future is in databases when it comes to helping solve crimes quicker. Everyone knows the value of having an intelligence sharing system. the meeting was a baby step, but a monumental step forward.’ One example Romley cited was the East Valley Gang and Criminal Fusion Center that consists of law enforcement agencies throughout the East Valley such as the Mesa, Tempe, Chandler, Gilbert and Scottsdale police departments sharing information through having all of their police reports in a database for investigative purposes.”

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[Post from Infoglide] Surface Web, Dark Web, and Social Media

“A recent article in Bank Systems & Technology  says that financial services institutions are discovering increasingly sophisticated attempts to defraud their customers – more sophisticated in how they gather information and employ it in their criminal schemes. ‘As fraudsters increasingly seek to exploit weaknesses in consumers’ defenses through social engineering schemes rather than hack vulnerabilities in banks’ security systems, the need for enterprisewide solutions to detect fraud across channels is greater than ever.’”

IT-Director.com: An Intelligent Match

“Buying rather than building speeds up the process of filling gaps in (or simply improving) functionality, and so is a logical step, and Experian itself has plenty of acquisition experience (including of course QAS itself). It opens up the intriguing possibility that Experian QAS may be looking in the future to spread its wings beyond its historically tight market of contact data management. If so then this may not be the last acquisition that it makes.”

AllBusiness: TSA “Secure Flight” Requirements

“Effective November 1, 2010, if you do not accurately provide the TSA with your full legal name as it appears on your government issued identification within 72 hours of a flight, your reservation could be canceled, at will, by the Transportation Security Administration (TSA). Why are they doing this?  To enhance the security of commercial air travel, the TSA has developed Secure Flight, a program that compares airline passenger information against U.S. government watch lists.”

InformationWeek: Top 10 Cloud Computing Complaints

“‘You need the ability to migrate data from one cloud service provider to another, and there are cloud interoperability scenarios that need to be addressed as well,’ notes Matt Edwards, director of the cloud services initiative at TM Forum, a communications industry association. ‘There are multiple things that need to be addressed to avoid vendor lock-in and to remove the barriers for the adoption of cloud services.’”

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By the Infoglide Team

Fraud Prevention: Medicare and Medicaid Fraud: US Healthcare Reform

“Earlier this year, a jury found Pfizer owed Wisconsin $9 million for violating the state Medicaid fraud law more than 1.4 million times by purposely overcharging the state for prescription drugs. The company faces potential fines from $140 million to $21 billion.”

Security Debrief: What is a Law Enforcement Fusion Center?

“Fusion centers that are doing strategic analysis are best positioned to prevent criminal acts. Trained intelligence analysts in these centers look at a local tip or Suspicious Activity Report (SAR) and then use advanced search tools across many databases simultaneously for indications that the tip could be part of a much bigger ‘iceberg’ hiding below the surface.”

ZDNet: Yankee Group: Infrastructure as a Service now a bona fide cloud strategy

“The survey of 400 enterprises finds ‘24 percent of large enterprises with cloud experience’ are already using IaaS, and an additional 37 percent expect to adopt IaaS during the next 24 months. ‘While adoption is still much slower than that of SaaS solutions, the market is gaining traction,’ says Yankee.”

Detroit Free Press: Tiny name differences on tickets not a worry

“Under its new ‘Secure Flight‘ process, the government compares airline passenger names, gender and birth dates with data on a terror watch list. However, a reservation or boarding pass that uses a middle initial instead of a full middle name, misses a hyphen, contains a tiny typo or leaves off the ‘Jr.’ designation should not cause a problem, according to the Transportation Security Administration.”

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[Post from Infoglide] The Not So Great Fortune 500 Enterprise

“Of the various types of crime involving fraud, individual cases of people scamming workers’ compensation garner the most publicity. The stories typically read like this: ‘Joe Blow was drawing workers’ comp while working as a personal trainer, and after he was caught on video, he had to pay back $9000 and received a five-year suspended jail sentence.’ While the human interest aspect of these stories, especially those including video of an injured worker involved in heavy physical activity, capture the most public attention, more organized activities impact the U.S. economy much more negatively.”

Cato Unbound: The Sky Isn’t Falling

“But a careful observer can detect the outlines of other intelligence successes based on surveillance in recent events. When David Headley was arrested for allegedly seeking to commit terrorist acts in Denmark, news reports suggested that one of the key factors in his identification was his pattern of travel to the Middle East and his efforts to conceal those trips from the government. Review of his travel both provided the trigger to ask questions and the factual cross-check on the veracity of his answers. Likewise, when Najibullah al-Zasi was arrested, one factor that was publicly disclosed as a ground for suspicion was surveillance of his travel to Pakistan.”

CIO: Healthcare Data Quality: Providing Better Patient Care

“Three things immediately jump to mind. The first is something very basic, but important: being able to identify a patient. Think of how many different ways might a patient’s name appear in a physician’s database. From misspellings to inconsistent middle name initial usage, multiple combinations of a name can lead to confusion. If healthcare providers don’t know who their patients are, how can they provide them with quality service?”

GovMonitor: Washington Cracks Down On Workers Compensation Fraud

“‘For every dollar Labor and Industries spends to combat fraud, we’ve seen an eight dollar return,’ Gregoire said. ‘By preventing and punishing fraud, we protect workers and honest businesses from unfair competition. Fraud in the workers’ compensation system hurts our economy – honest businesses are undercut by those that don’t fairly participate in the system and workers pay more than they should when others claim more benefits than they deserve.’”

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