“The indictment alleges that Tiwari defrauded health care benefit programs including Medicare, Indiana Medicaid and Anthem Blue Cross Blue Shield, and that from 2002 through 2007, he was paid more than $21 million by those three programs alone. Tiwari does business as The Pain Management Center of Southern Indiana P.C., The Pain Management & Surgery Center of Southern Indiana Inc., and Southern Indiana Anesthesiology P.C., formerly known as Kamal Tiwari Inc. P.C.”
“All passengers flying domestically and internationally on US airlines are now being checked against government watch lists through the Transportation Security Administration’s (TSA) Secure Flight program, DHS Secretary Janet Napolitano announced late last week… TSA began implementing Secure Flight in late 2009 and expects all international carriers with direct flights to the United States to begin using Secure Flight by the end of 2010.”
“Gartner, a highly regarded research firm and consultancy organization, has been tracking the entity-resolution market for several years and stated in a recent report: ‘Entity resolution and analysis was previously an obscure technology that has come to the forefront as a result of world events and market forces where it is used to identify the use of false identities and networks of individuals who are attempting to hide their relationships to each other.’”
“Last week Rep. Scott Murphy of Glen Falls (D-NY) told a House panel that more effective policing of Medicare and Medicaid fraud claims is imperative in order to reduce the estimated $60 billion in fraudulent claims that is disbursed each year. We agree with the expressed intent, and we are hopeful that CMS and others involved in decision-making will take advantage of any and all technologies to stamp out fraud, including identity resolution.”
“The scheme to defraud is alleged to have begun in April 2004, through Logic World, with the last allegedly false claim having been filed in February 2010 through Roben Medical. During this time period, Essien and Akpan allegedly billed and caused the billing of Medicaid for claims totaling approximately $2,341,293.64 and received payments for those claims totaling approximately $1,455,837.91.”
“The Congressional Budget Office estimates electronic health records could save the U.S. $12 billion over 10 years, which seems very modest in comparison to the estimated $2.2 trillion spent on healthcare in the U.S in 2010. While workers’ compensation medical bill payers are not covered entities under HIPAA they will be required to have “business associate agreements” with HIPAA covered entities for the electronic exchange of patient health information. It remains to be seen how this will force workers’ compensation payers to modify their business practices.”
“A recent video story on KING5 in Seattle highlighted the aggressive efforts state agencies take to ferret out employment fraud. This particular story highlights an agency’s success in identifying and prosecuting unlicensed contractors.”
Last week Rep. Scott Murphy of Glen Falls (D-NY) told a House panel that more effective policing of Medicare and Medicaid fraud claims is imperative in order to reduce the estimated $60 billion in fraudulent claims that is disbursed each year. We agree with the expressed intent, and we are hopeful that CMS and others involved in decision-making will take advantage of any and all technologies to stamp out fraud, including identity resolution.
The press has reported repeatedly that both the Medicare (federal) and Medicaid (state) programs are riddled with fraud. Unscrupulous doctors, medical supply firms, and others involved in the healthcare supply chain are able to extract millions up millions of dollars of taxpayer money from these government programs.
A recent example reported by the Miami Herald told how the Miracle Group Rehabilitation Center was “falsely billing the federal healthcare program $3.1 million over just three months. Medicare paid Ramos $1.9 million for rehab services never provided to angry beneficiaries… This past year, CMS paid approximately $60 billion to criminals impersonating doctors and patients in order to file false claims.” Multiply this by the thousands of dishonest people who abuse these systems and you can easily exceed the $60 billion estimate!
So what is being done? The federal government included legislation targeting healthcare fraud in the comprehensive healthcare bill it passed last year. As we’ve reported before, many states are passing legislation as well.
Passing stiffer laws is great, yet we’re certain the information needed to stop most of the fraud is in data already held by government agencies. 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.
It appears to be a matter of educating those in power about existing technology and having the political resolve to apply it. We hope that happens soon.
“Notwithstanding the fact that IT seems to always have the latest, greatest thing on its mind, cloud computing has the entire IT industry excited, with companies such as IBM, Microsoft, Amazon, Google and others investing billions of dollars in this new form of computing. And in terms of IT users, Gartner recently named cloud computing as the second most important technology focus area for 2010.”
“This past year, CMS paid approximately $60 billion to criminals impersonating doctors and patients in order to file false claims. Medicare and Medicaid fraud not only affects those covered by the insurance plan, but every single taxpayer nationwide, regardless of party affiliation, Murphy said.”
“Investigators said the business is engaged in roofing and demolition work, but that the DiNapolis allegedly misrepresented themselves as cleanup contractors for debris at demolition sites of other contractors. They allegedly also falsely gave their business location as upstate Jefferson, NY, rather than Kings Park, which further resulted in paying a lower workers’ comp. premium.”
“The facility would also serve as a regional ‘fusion center‘ favored by the U.S. Department of Homeland Security, Gillison said, with at least one federal intelligence analyst to coordinate street-level intelligence nationally and among 11 counties in Pennsylvania, New Jersey, Delaware, and Maryland. It also would become headquarters for the Southeast Pennsylvania Regional Task Force, the five-county panel of emergency-response officials that coordinates antiterrorism and disaster efforts.”
“A recent video story on KING5 in Seattle highlighted the aggressive efforts state agencies take to ferret out employment fraud. This particular story highlights an agency’s success in identifying and prosecuting unlicensed contractors. Such willingness to work around licensing regulations can also signal a cavalier attitude about providing workers’ compensation insurance to employees as required by law.”
“The IOC-2 is co-located at the Organized Crime Drug Enforcement Task Forcefusion center and the DEA’s Special Operations Division Command Center, which are both in northern Virginia. Partner agencies meet in a task force setting where they provide information and intelligence reports that might pertain to international organized crime. When Holder announced the center, he also emphasized the importance of continued cooperation with foreign law enforcement through existing police-to-police and mutual legal assistance mechanisms.”
“The state of Kansas has been conducting ’sting’ operations to prevent this kind of theft by lottery terminal clerks. Law enforcement agents fanned out across the state and presented ‘winning’ tickets at several retail lottery outlets. In five separate cases clerks told the agents the tickets were worthless and then tried to redeem the ‘winning’ lottery tickets. The undercover investigation led to charges of attempted theft and computer crime against five people across the state. Lottery officials across the country advise lottery players to check their own tickets.”
“Costa said that a more effective fight against the crime syndicates requires shifting ‘focus from disrupting the mafias to disrupting their markets’ through tighter measures to combat money laundering and corruption. He also suggested cracking down on the accomplices of crime ‘like the army of white-collar criminals — lawyers, accountants, realtors and bankers who cover up and launder their proceeds.’”
A recent video story on KING5 in Seattle highlighted the aggressive efforts state agencies take to ferret out employment fraud. This particular story highlights an agency’s success in identifying and prosecuting unlicensed contractors. Such willingness to work around licensing regulations can also signal a cavalier attitude about providing workers’ compensation insurance to employees as required by law.
Many organizations face the challenge of identifying individuals or businesses that intend to deceive by altering their identity in some manner. Detecting employer fraud in workers’ comp is an example that has been highlighted in a journal article:
In order to avoid paying premiums, a company’s owners may illegally classify permanent employees as contractors. Alternately, they may operate for some time without paying their premiums, and then when the insurer is about to take action, they simply shut down the company on paper and reconstitute it under another name. Companies also use this “going out of business” ploy in cases where their experience (or modification) rating has gone up due to multiple injuries, thereby resulting in higher premiums. By reopening as another company, they can effectively reset their experience rating.
Entity analytics uses a combination of similarity searching and transitive matching to alert authorities about companies or contractors that advertise themselves as open for business and who are related to companies or contractors as known offenders. Enhancing existing systems in this way with entity resolution makes them even stronger.
“Crown prosecutors said they will likely be able to collect about $6.1-million, about $450,000 less than what Mr. Malik owes from the original winnings, including interest. That money will be returned to the Ontario Lottery and Gaming Corp., which paid the money to the real winners, plus interest, when it discovered Mr. Malik’s fraud.”
“ICE’s experience in trade-based money laundering investigations has shown that one of the most effective ways to identify instances and patterns of trade-based money laundering is through the exchange and subsequent analysis of trade data for anomalies that would only be apparent by examining both sides of a trade transaction.”
“McClain heads up Contractor Compliance for the agency and has just 27 inspectors to cover the state. The agency registers 55,000 contractors each year, so reigning in folks like Mulinski is a difficult task. ‘Finding them working on a job site is a real challenge,’ he said. Once we find them there, knowing that they are registered, who are employees and who are workers?’”
“Stories about financial services fraud are on the rise. Consider the recent article about an employee of a financial services company who had charges filed against him for conspiring to rig bids for investments in municipal bond projects…”
“According to court documents: Zaino engaged in a bid-rigging conspiracy from at least as early as October 2001 until March 2006. As a part of the bid-rigging conspiracy, Zaino, acting as a broker of investment agreements, and co-conspirator providers designated in advance which co-conspirator provider would be the winning bidder for certain investment agreements brokered by Zaino’s employer.”
“‘ASTA has and will continue to work closely with the TSA to notify members through member alerts and updates, of upcoming changes and deadlines that impact the travel agency community and the traveling public. We have, throughout the implementation period, met with TSA and provided updates and direction to our members regarding compliance,’ said ASTA President and Chair Chris Russo.”
Stories about financial services fraud are on the rise. Consider the recent article about an employee of a financial services company who had charges filed against him for conspiring to rig bids for investments in municipal bond projects:
“According to court documents: [Mark] Zaino engaged in a bid-rigging conspiracy from at least as early as October 2001 until March 2006. As a part of the bid-rigging conspiracy, Zaino, acting as a broker of investment agreements, and co-conspirator providers designated in advance which co-conspirator provider would be the winning bidder for certain investment agreements brokered by Zaino’s employer. After the winning co-conspirator provider was designated, Zaino caused the other co-conspirator providers to submit intentionally losing bids, giving the false appearance that the investment agreements had been bid competitively in accordance with relevant Treasury regulations.”
If you’re familiar with the capabilities of identity resolution, this is a classic case of uncovering hidden entity relationships. Warning signs about Zaino’s alleged relationships with several providers were almost certainly available. Connecting the right set of disparate databases and using similarity searching and transitive matching would have certainly turned up Zaino’s connections to his alleged co-conspirators.
We’ve been involved in detecting insider trading, a similar type of fraud. In writing about available data sources, we said that “besides lists that individuals put together and post on the web, public and private databases offer all sorts of information on people that are useful in addressing multiple types of business problems and opportunities,” and we went on to list a few.
In addition to these types of data, financial institutions have their own massive data sets derived from operations. Combining their internal data with easily obtainable external public and private source offers opportunities to avoid the kind of bad publicity associated with that lead story above.
It all begs the question: Why aren’t more organizations protecting themselves with commercial due diligence systems using identity resolution?
“Department of Homeland Security (DHS) Secretary Janet Napolitano today announced that 100 percent of passengers traveling within the United States and its territories are now being checked against terrorist watchlists through the Transportation Security Administration’s (TSA) Secure Flight program—a major step in fulfilling a key 9/11 Commission recommendation.”
“The center, which is housed in the FBI’s Fort Myers office near Gateway, is designed to digest and compare data from across the region. Once complete, Storrar said the center will help local officials bridge jurisdictional, historical and technological barriers. It will help law enforcement, fire and health officials look for red flags, connect dots and provide threat assessments, Storrar said.”
“In the case of Teodoro Nguema Obiang Mangue, the son of the president of Equatorial Guinea, the report said two lawyers helped him bypass anti-money-laundering laws by allowing him to use shell company accounts as conduits for his funds without telling U.S. bankers that Obiang was using the accounts. ‘If a bank later uncovered Mr. Obiang’s use of an account and closed it, the lawyers helped him set up another,’ it said.”
“Officials said health care providers at the centers who demonstrate ‘meaningful use’ of EHRs could be eligible for federal incentive payments through Medicaid and Medicare.”
Infoglide Software provides entity resolution and analysis solutions for retail, banking, insurance, government, and law enforcement. Without the need for data cleansing or warehousing, Infoglide Software's Identity Resolution Engine™ (IRE) analyzes all of the information relating to individuals and/or entities from multiple sources of data and then applies...
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