Fraud Investigation

Fraud investigations are used to expose a fraudulent offense and to punish the perpetrator for this deceitful and illegal act. A fraud investigation is conducted to protect and offer justice to the victim of a fraudulent offense, and in turn to punish the fraudster responsible for the offense.

The healthcare industry ranks fourth among all industries for several occupational fraud cases reported annually, with most cases occurring in the areas of corruption and billing schemes. Past data has shown that healthcare fraud costs approximately 68 billion each year – approximately 3% of the nation’s healthcare spending.

Investigations into healthcare fraud generally begin with formal allegations, which can come from a variety of sources. An estimated 40% of fraud detections come from suggestions, with most suggestions coming from employees.3 External parties such as suppliers or customers can also be detected Potentially fraudulent activity can be detected during a routine internal or external audit. Reports can also be sent directly to management or the compliance department. Organizations should put in place a method for individuals to report complaints anonymously. whether written or oral should be documented and communicated to the appropriate parties for further investigation.

Regardless of the source of the allegation, the organization must assemble a team of people with the necessary experience to conduct a successful investigation. The team will likely consist of internal and external parties, depending on the nature of the allegations, the extent of the potential financial or business risk, and the size of the organization. Team members should have clearly defined roles and responsibilities. The Start After the investigation, the team should have a primary point of contact set up. Communication flow and information distribution between internal and external stakeholders during the investigation. Therefore, the contact should have adequate authority to make decisions on behalf of the organization or in consultation with senior management. devote yourself to research, it could take up your entire schedule.

Once the team has been established, it should conduct initial discussions to obtain background information about the fraud allegation. The purpose of these discussions should be to:

Understand the context of the issue

Reveal the identity of individuals with relevant information

Establish the availability of evidence

Once an organization is aware of a fraud allegation, it is important to take steps to preserve any electronic and hard copy evidence that might exist. The steps to preserve evidence may vary depending on whether the organization intends to end the issue, take the person on administrative leave, or not take immediate action against the person until the investigation is complete.

1: If an employee is fired at the beginning of an investigation, all electronic devices issued by the company in the individual’s possession should be collected. Equipment must be kept in the custody of the primary contact for the investigation team. The organization’s network must be revoked immediately.

2:  If an employee is not fired or on leave, but remains on the staff and is unaware of the investigation, efforts should be made to secretly access the employee’s electronic devices if they are available on the company’s premises. the employee’s office or workplace is also recommended.

The investigation team must develop a comprehensive approach to analyzing financial, business, and electronic records applicable to fraud investigations.

The organization must use an analytical approach that combines rule-based analysis, machine learning-based algorithms, and data visualizations to identify fact patterns. Investigation teams must also consider an effective approach to analyzing electronically stored information. This type of analysis can be performed in-house or through an external eDiscovery provider that uses software that can extract and analyze data relevant to the investigation.

Interviews with witnesses and the object of investigation must be carefully planned. It is a good idea to conduct the interviews after analyzing most of the financial, business, and electronic records so that the questions can become more focused. :

1:When should the interview be scheduled concurrently?

2:What is the appropriate order of the interviews?

3:Should an in-house lawyer be present during employee interviews?

4:When should the interviews occur?

When the investigation is complete and the investigation team writes the report, it is important to consider the target audience. For example, the reports can be used to file claims against insurance companies to collect losses due to employee theft. At the start of an investigation and during the reporting phase, review the requirements for the organization’s insurance company. Take into account coverage periods and loss limits.

If the organization decides to take criminal action against a person, it is customary to use the investigation report to refer the case to the police. , State or federal agencies may be interested in the case. All original evidence should be retained alongside the report.

Fraud Investigation

Foglight PI