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Pondera FraudCast

Welcome to the Pondera FraudCast, a weekly blog where we post information on fraud trends, lessons learned from client engagements, and observations from our investigators in the field. We hope you’ll check back often to stay current with our efforts to combat fraud, waste, and abuse in large government programs.

Ugly Case of Health Care Fraud

Ugly Case of Health Care Fraud

A few weeks ago, I published a blog post titled “Money Obtained Fraudulently is Rarely Used for Good Purposes”. In it, I made the argument that government fraud is a serious, and at times very ugly problem. Now I no longer have to make that argument because the United States Justice Department is making the argument for me.

Last week, the Justice Department announced the largest health care fraud case it’s ever prosecuted; one that defrauded over $1 billion over the past 14 years. The alleged perpetrators of the fraud are said to have leased private jets and chauffeured limousines. One even bought a $600,000 watch! Remember, this is your tax money we’re talking about. The system ran on a complex network of bribes and kickbacks.

And if that’s not enough, here is one of the schemes they allegedly ran. They “treated” seemingly healthy, elderly people with medications they did not need in order to create addictions which would lead to further treatments. Pure evil. Unfortunately, fraudsters are most active where large amounts of money meet vulnerable populations. This is yet another example of that and more reason for us to do what we do.
The False Positive Problem

The False Positive Problem

Last year, 60 Minutes did a segment on the impact of errors in the Social Security Administration’s Master Death File—a database that stores dates of death for Americans. The system stores 86 million records, and despite all best efforts, it still has some issues.

60 Minutes pointed out that errors in the system contribute to millions of dollars in improper payments each year. After all, the system would seem to indicate over 6.5 million Americans over the age of 111 when, in fact, there are probably fewer than 100. On the other hand, false positives where people find themselves mistakenly placed on the list, lead to nightmarish scenarios for obtaining loans, opening bank accounts, and other everyday tasks.

This story demonstrates one of the largest challenges for government agencies: how to use imperfect data sources to minimize fraud, waste, and abuse while also not “harassing” legitimate people and businesses. And unlike a private business that may view a false positive as an inconvenience (who hasn’t had to call their credit card company to say that “yes, that large ice cream purchase was legitimate”), government officials are severely criticized when they act on false positives. In effect, they are criticized for not acting and they are criticized for acting.

Pondera suggests that governments mitigate the effects of false positives by using composite indicators that draw information from multiple sources—both simple data matches like the Master Death File and more complex behavioral sources. For example, a Medicaid investigator would feel much more confident looking into a person who not only shows up on the Master Death File, but also appears to be traveling 100 miles for 20-minute doctor appointments, receives highly unusual (and expensive) procedures for their apparent diagnosis, and often sees two doctors in distant cities on the same day.

Anyone who has worked for or with government program integrity units understands the unique pressures they face. Combining available data sources with intelligent analytics can go a long way toward helping them investigate the right cases while not interfering with program delivery.
Pondera’s High Potential Leader:  Amanda Huston

Pondera’s High Potential Leader: Amanda Huston

Established in 1636, Harvard University is the United States' oldest institution of higher learning and one of the world's most prestigious universities. A couple of weeks ago, I had the remarkable opportunity to participate in the Harvard Business School Executive Education Program for High Potential Leaders. To step foot on this amazing campus filled with brick buildings plush with deep green climbing ivy, you almost immediately feel like you are part of something special (or perhaps inside some Matt Damon/Ben Affleck movie). Stepping foot in the state-of-the-art classroom with the instructor "pit" in the center, surrounded by 100 of the world's most talented and up-and-coming leaders, I wondered if I fit in this group or would have any common ground.

My learning group, a smaller team designed to facilitate debate and discussion on assigned topics, included eight talented young professionals; only two originally from the United States. They represented a variety of industries, none of which had anything to do with mine.

What I learned by working with this group, is that despite my initial hesitation, we were far more alike than I could have imagined. No matter their business, job title, or Country of operation, we faced so many of the same challenges and experiences in our professional lives. During one group activity, I began to think about how this applied to the clientele I serve at Pondera. Whether it's a small State unemployment program or the Nation's largest Medicaid program, these teams of dedicated professionals face so many of the same challenges and share similar experiences. Perhaps, I could bring them together through the Pondera client network and facilitate cross-state, cross-program sharing and learning. My brain was really starting to kick into high gear now.

Reflecting back on my time at Harvard, I decided to focus on the key ways I could translate my experience into benefit for my company and clients. I decided upon three themes:

  • Bold, passionate, inspiring leaders can change everything. No matter if you are managing financial accounts worth billions or a Government employee overseeing a Federal entitlement program, the culture created from these kinds of leaders brings success to the whole organization. Skills can be taught, management can be improved, but make no mistake, there is no substitute for extraordinary leadership. We must find these leaders, and then cultivate and cherish them.
  • Networks are critical to continued learning and success; make time to grow and nurture yours. Your network could be persons within or outside of your organization, family, friends, peers, professional mentors, etc. Networks serve as a vibrant source of creative energy, partnership, and may just offer the solution to whatever challenge you or your organization is facing. Make time in your daily grind to have a coffee, make a quick call, or even share a meal with key persons in your network.
  • Always be willing to adapt and evolve or be prepared for extinction. This is especially true in leading innovation, particularly in the data analytics arena. Fraud schemes change, data sources emerge, programs transform. At Pondera, we can never get comfortable or diminish our aggressive pursuit to lead the way. Governments must embrace the "information age" and transform their processes, modernize their programs, and challenge the status quo.

Graduation

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Pondera leverages advanced prediction algorithms and the power of cloud computing to combat fraud, waste, and abuse in government programs.



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